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Pei KY, Schwartz TA, Boermeester MA. Practical Guide to Curricular Development Research. JAMA Surg 2024:2813490. [PMID: 38170534 DOI: 10.1001/jamasurg.2023.6699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
This Guide to Statistics and Methods provides an overview of performing curricular development research.
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Affiliation(s)
| | - Todd A Schwartz
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill
- Statistical Editor, JAMA Surgery
| | - Marja A Boermeester
- Department of Surgery, Amsterdam University Medical Centers, Amsterdam, the Netherlands
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Nwokedi U, Graviss EA, Nguyen DT, Pei KY. Work relative value units undervalue the clinical effort associated with teaching cases: An ACS-NSQIP analysis. Am J Surg 2024; 227:117-122. [PMID: 37806890 DOI: 10.1016/j.amjsurg.2023.09.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 09/27/2023] [Accepted: 09/30/2023] [Indexed: 10/10/2023]
Abstract
PURPOSE Work-relative-value-units (wRVUs) are a core metric of faculty effort but do not account for the additional work associated with intraoperative teaching. This study introduces and assesses an indexed effort, wRVU per minute (wRVU index). We hypothesize that there is a significant decrease in the calculated wRVU index among teaching cases. METHODS We queried the ACS-NSQIP database for 7 core Emergency General Surgery procedures and records were stratified into teaching vs non-teaching, and emergent vs non-emergent procedures. We utilized multivariable generalized linear models to determine factors associated with increased operative time and decreased wRVU index. RESULTS Data were available for 953,967 cases from 2005 to 2010. For all cases, teaching vs non-teaching, the median wRVU index was 0.16 vs 0.21 (p < 0.001). There was a positive association between teaching cases and decreased wRVU index for all cases. CONCLUSION The wRVU index was 24% lower for teaching cases when compared to non-teaching cases despite controlling for patient-specific factors. This finding highlights the need for further evaluation of the current wRVU framework.
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Affiliation(s)
- Ugoeze Nwokedi
- Department of Graduate Medical Education, Parkview Health, Fort Wayne, Indiana, USA.
| | - Edward A Graviss
- Department of Surgery, Houston Methodist Hospital, Houston, TX, USA; Department of Pathology and Genomic Medicine, Houston Methodist Research Institute, Houston, TX, USA
| | - Duc T Nguyen
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Kevin Y Pei
- Department of Graduate Medical Education, Parkview Health, Fort Wayne, Indiana, USA
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3
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DiFiori MM, Gupta SS, Cannada LK, Pei KY, Stamm MA, Mulcahey MK. Bullying in Orthopaedic Surgery: A Survey of US Orthopaedic Trainees and Attending Surgeons. J Am Acad Orthop Surg Glob Res Rev 2023; 7:01979360-202305000-00006. [PMID: 37141506 PMCID: PMC10155897 DOI: 10.5435/jaaosglobal-d-23-00007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Accepted: 02/10/2023] [Indexed: 05/06/2023]
Abstract
INTRODUCTION Bullying is a notable problem in surgery, creating a hostile environment for surgeons and trainees, and may negatively affect patient care. However, specific details regarding bullying in orthopaedic surgery are lacking. The primary aim of this study was to determine the prevalence and nature of bullying within orthopaedic surgery in the United States. METHODS A deidentified survey was developed using the survey created by the Royal College of Australasian Surgeons and the validated Negative Acts Questionnaire-Revised survey tool. This survey was distributed to orthopaedic trainees and attending surgeons in April 2021. RESULTS Of the 105 survey respondents, 60 (60.6%) were trainees and 39 (39.4%) were attending surgeons. Although 21 respondents (24.7%) stated they had been bullied, 16 victims (28.1%) did not seek to address this behavior. Perpetrators of bullying were most commonly male (49/71, 67.2%) and the victims' superior (36/82, 43.9%). Five bullying victims (8.8%) reported the behavior, despite 46 respondents (92.0%) stating that their institution has a specific policy against bullying. CONCLUSION Bullying behavior occurs in orthopaedic surgery, with perpetrators being most commonly male and the victims' superiors. Despite the fact that an overwhelming majority of institutions have policies against bullying, the reporting of such behavior is lacking.
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Affiliation(s)
- Monica M DiFiori
- From the Department of Orthopaedic Surgery and Sports Medicine, Temple University Hospital, Philadelphia, PA, (Dr. DiFiori); Tulane University School of Medicine, New Orleans, LA (Ms. Gupta); Department of Orthopaedics, University of North Carolina and Novant Health Orthopaedic Fracture Clinic, Hughston Clinic, Jacksonville, FL (Dr. Cannada); Graduate Medical Education, Parkview Health, Fort Wayne, Indiana (Dr. Pei); Department of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, LA (Dr. Stamm and Dr. Mulcahey)
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Pei KY, Klingensmith ME. Ethical challenges in education research during high stakes events - can participants truly "opt-out?". Am J Surg 2023; 225:258-259. [PMID: 35773039 DOI: 10.1016/j.amjsurg.2022.06.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Revised: 06/17/2022] [Accepted: 06/18/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Kevin Y Pei
- Parkview Health Graduate Medical Education, Fort Wayne, IN, USA.
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Purnell SM, Pei KY, Tilton J, Bloom A, Dickinson K, Zheng F. Utilizing Change Management Theory to Optimize Resources and Reduce Supply Chain Costs. Am Surg 2023; 89:325-327. [PMID: 33170032 DOI: 10.1177/0003134820952830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
| | - Kevin Y Pei
- 23534Houston Methodist Hospital, Houstan, TX, USA
| | - Julie Tilton
- 23534Houston Methodist Hospital, Houstan, TX, USA
| | - Alexi Bloom
- 23534Houston Methodist Hospital, Houstan, TX, USA
| | | | - Feibi Zheng
- 23534Houston Methodist Hospital, Houstan, TX, USA
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Bourdillon AT, Kafle S, Salehi PP, Steren B, Pei KY, Azizzadeh B, Lee YH. Characterization of Laryngotracheal Fractures and Repairs: A TQIP Study. J Voice 2022:S0892-1997(22)00163-1. [PMID: 35817623 DOI: 10.1016/j.jvoice.2022.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 06/06/2022] [Accepted: 06/08/2022] [Indexed: 11/22/2022]
Abstract
OBJECTIVES Laryngotracheal trauma is poorly studied and associated with serious morbidity and mortality. This study reports features associated with laryngotracheal fractures, and factors associated with laryngeal fracture repair. STUDY DESIGN Retrospective database study SETTING: American College of Surgeons Trauma Quality Improvement Program (ACS-TQIP®) METHODS: ACS-TQIP® 2014-2015 participant user data files were queried for laryngotracheal fractures using the International Classification of Diseases (ICD) 9th edition encodings. Demographic, diagnostic and procedure characteristics were analyzed with univariate chi-squared analysis and multivariate logistic regression. RESULTS We extracted 635 cases of laryngotracheal injury, with a median Injury Severity Score of 16 (IQR: 10 - 25). Most were caused unintentionally (65.7%), followed by assault (28.8%). Blunt trauma (79.5%) was more common than penetrating trauma (20.0%). These trends were upheld in the subgroup of repaired fractures, which made up 12.6% (80/635) of cases. The median length of hospital stay was 6 days (IQR: 3 - 13) in all fractures and 10 days (IQR: 6 - 14) in the subgroup of repaired fractures, while the median length of ICU stay was 4 days (IQR: 2 - 9) in all fractures and 4.5 (IQR: 6 - 14.3) in the subgroup of repaired fractures. Cut/pierce injuries (OR: 4.7, P < 0.001) and ISS (OR: 0.97, pP = 0.026) significantly affected rate of laryngeal fracture repair. CONCLUSION Laryngotracheal fractures are uncommon but serious injuries. Our results show that penetrating causes of injuries have the shortest time to repair, and that a higher ISS score is negatively associated with repair.
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Affiliation(s)
| | - Samipya Kafle
- Yale School of Medicine, Yale University, New Haven, CT
| | - Parsa P Salehi
- Division of Otolaryngology, Department of Surgery, Yale School of Medicine, New Haven, CT
| | | | - Kevin Y Pei
- Department of Surgery, Parkview Health, Fort Wayne, IN
| | - Babak Azizzadeh
- Center for Advanced Facial Plastic Surgery, Beverley Hills, CA; Division of Head and Neck Surgery, Department of Otolaryngology-Head and Neck Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA
| | - Yan Ho Lee
- Division of Otolaryngology, Department of Surgery, Yale School of Medicine, New Haven, CT.
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Yazid MM, De la Fuente Hagopian A, Farhat S, Doval AF, Echo A, Pei KY. Does Surgeon Specialty Make a Difference in Ventral Hernia Repair With the Component Separation Technique? Cureus 2022; 14:e26290. [PMID: 35898356 PMCID: PMC9308972 DOI: 10.7759/cureus.26290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/24/2022] [Indexed: 11/05/2022] Open
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Abstract
OBJECTIVES Bullying is defined as the perception of negative actions in which the target has difficulty in defending themself. This may include verbal, physical, or psychological force used to influence behavior. We sought to understand factors associated with bullying identified in vascular surgery trainees as well as barriers to reporting. METHODS An anonymous electronic survey consisting of demographic information and validated scales for bullying (NAQ-R), social support, and grit was sent to vascular surgery trainees in the United States. Respondents who reported bullying were compared to those who were not bullied. RESULTS Of the 516 invitations sent, 132 (26%) completed the survey. 63/132 (48%) reported being bullied or witnessed a fellow trainee being bullied in the past 6 months, with 42 (32%) reporting being bullied. Gender, marital status, paradigm of vascular training, grit level, and social support did not predict reception of bullying, although those in the highest quartile of grit showed a trend towards lower NAQ-R scores (p=0.06). As expected, trainees that reported receiving bullying had a higher NAQ-R (p<0.0001). No trainee reported daily bullying but 52% reported bullying "now and then" or several times a week. The most common perpetrator was their direct superior surgeon, although 12 (29%) reported bullying from co-residents and 6 (14%) reported bullying from patients. 15/42 (36%) did not address the bullying behavior, and the most common barriers to reporting bullying identified were fear of loss of support from supervisor (48%), loss of reputation (45%), and effect on career choices (43%). Of those who reported addressing the behavior, 56% reported the behavior continued. 70/132 (53%) reported no knowledge of institution-specific policies to address bullying in their program. The most common reasons identified for why bullying may occur in vascular training programs are "high stress environments" and "learned behavior" from others. CONCLUSIONS Bullying occurs in a significant amount of vascular trainees, but there are no clearly identified factors predictive of who will receive bullying. Trainees with higher grit may experience less bullying or more likely have a lower perception of bullying behavior. Further research is needed to determine the effects of bullying on vascular trainees.
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Affiliation(s)
- Jon P Orlino
- Division of Vascular and Endovascular Surgery, Department of Surgery, Saint Louis University, Saint Louis, Missouri.
| | - Tej A Sura
- Saint Louis University School of Medicine, Saint Louis, Missouri
| | | | - Matthew R Smeds
- Division of Vascular and Endovascular Surgery, Department of Surgery, Saint Louis University, Saint Louis, Missouri.
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Affi Koprowski M, Dickinson KJ, Johnson-Mann CN, Godfrey M, Diego EJ, Crandall M, Pei KY. Cross-mentorship: A Unique Lens Into the Realities and Challenges of Diversity in Surgery. Ann Surg 2022; 275:e6-e7. [PMID: 34520426 DOI: 10.1097/sla.0000000000005213] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
| | - Karen J Dickinson
- Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Crystal N Johnson-Mann
- Division of Gastrointestinal Surgery, Department of Surgery, University of Florida College of Medicine, Gainesville, FL
| | - Martha Godfrey
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL
| | - Emilia J Diego
- Division of Surgical Oncology, Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Marie Crandall
- Division of Acute Care Surgery, Department of Surgery, University of Florida College of Medicine, Jacksonville, FL
| | - Kevin Y Pei
- Department of Surgery, Parkview Health Graduate Medical Education, Fort Wayne, IN
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Dickinson KJ, Bass BL, Graviss EA, Nguyen DT, Pei KY. Independent Operating by General Surgery Residents: An ACS-NSQIP Analysis. J Surg Educ 2021; 78:2001-2010. [PMID: 33879397 DOI: 10.1016/j.jsurg.2021.03.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 02/15/2021] [Accepted: 03/21/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVE Surgical resident autonomy during training is paramount to independent practice. We sought to determine prevalence of general surgery resident autonomy for surgeries commonly performed on emergency general surgery services and identify trends with time. DESIGN We queried ACS-NSQIP for patients undergoing one of 7 emergency general surgery operations. We evaluated trends in independent operating (defined as a resident operating alone, without attending having scrubbed) over the study period. Other outcomes of interest: operative time, 30-day-mortality and complications. SETTING The ACS-NSQIP database. PARTICIPANTS Patients undergoing one of 7 emergency general surgery operations. RESULTS Data regarding resident involvement was only available for the years 2005-2010. 90,790 operations were performed, 922 (1%) by residents operating independently. Appendectomy accounted for 61% independent cases. Independent resident operating was associated with a longer operative time (65 versus 58 minutes, p < 0.001), but lower risk of bleeding requiring transfusion (p < 0.001) and progressive renal insufficiency (p = 0.02). Independent operating was not associated with increased risk of complications/mortality. CONCLUSION Independent resident operating is rare, even with increasing attention to its importance, and is not associated with increased complications or mortality. National data on this subject is old and not currently collected. There is need for a national registry on resident involvement to understand the current effect of independent operating on outcomes.
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Affiliation(s)
- Karen J Dickinson
- Department of Surgery, Houston Methodist Hospital, Houston, Texas; Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas.
| | - Barbara L Bass
- George Washington University School of Medicine and Health Services, Washington DC
| | - Edward A Graviss
- Department of Surgery, Houston Methodist Hospital, Houston, Texas; Department of Pathology and Genomic Medicine, Houston Methodist Research Institute, Houston, Texas
| | - Duc T Nguyen
- Department of Pathology and Genomic Medicine, Houston Methodist Research Institute, Houston, Texas
| | - Kevin Y Pei
- Department of Graduate Medical Education, Parkview Health, Fort Wayne, Indiana
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Dickinson KJ, Caldwell KE, Graviss EA, Nguyen DT, Awad MM, Tan S, Winer JH, Pei KY. Assessing learner engagement with virtual educational events: Development of the Virtual In-Class Engagement Measure (VIEM). Am J Surg 2021; 222:1044-1049. [PMID: 34602277 DOI: 10.1016/j.amjsurg.2021.09.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 09/22/2021] [Accepted: 09/22/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND The COVID-19 pandemic has necessitated virtual education, but effects on learner engagement are unknown. We developed a virtual in-class engagement measure (VIEM) to assess learner engagement in online surgical education events. METHODS Using the STROBE, an observer collected tool to document student engagement, as a template an ASE committee workgroup developed the VIEM. The VIEM had two parts: observer assessment and learner self-assessment of engagement. Trained observers collected engagement data from two institutions using the VIEM. Surgical attendings, fellows and residents were observed during virtual learning events. Educator attitudes towards online teaching were also assessed via survey. RESULTS 22 events with 839 learners were observed. VIEM distinguished between sessions with low and high engagement. 20% of learners pretended to participate. Half of instructors were comfortable with virtual teaching, but only 1/3 believed was as effective as in-person. 2/3 of teachers believed video learners were more engaged than audio learners. CONCLUSIONS Virtual platforms do not automatically translate into increased engagement. Standard tools such as VIEM may help with assessment of engagement during virtual education.
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Affiliation(s)
- K J Dickinson
- Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA; Department of Surgery, Houston Methodist Hospital, Houston, TX, USA; Department of Interprofessional Education, University of Arkansas for Medical Sciences, Little Rock, AR, USA.
| | - K E Caldwell
- Department of Surgery, Washington University in St Louis, St Louis, MO, USA
| | - E A Graviss
- Department of Surgery, Houston Methodist Hospital, Houston, TX, USA; Department of Pathology and Genomic Medicine, Houston Methodist Research Institute, Houston, TX, USA
| | - D T Nguyen
- Department of Pathology and Genomic Medicine, Houston Methodist Research Institute, Houston, TX, USA
| | - M M Awad
- Department of Surgery, Washington University in St Louis, St Louis, MO, USA
| | - S Tan
- Department of Surgery, University of Florida Health, Gainesville, FL, USA
| | - J H Winer
- Department of Surgery, Emory University, Atlanta, GA, USA
| | - K Y Pei
- Department of Graduate Medical Education, Parkview Health, Fort Wayne, IN, USA
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Bourdillon AT, Salehi PP, Lee JY, Steren B, Pei KY, Lee YH. Demographic, Clinical, and Mortality Trends of Law Enforcement-Related Trauma: A Trauma Quality Improvement Program Analysis. JAMA Surg 2021; 156:685-687. [PMID: 33950217 DOI: 10.1001/jamasurg.2021.0697] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
| | - Parsa P Salehi
- Division of Otolaryngology, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Jonathan Y Lee
- Department of Surgery, Division of Plastic and Reconstructive Surgery, University of Massachusetts Medical School-Baystate, Springfield
| | | | - Kevin Y Pei
- Department of Surgery, Houston Methodist Hospital, Houston, Texas
| | - Yan Ho Lee
- Division of Otolaryngology, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
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Resio BJ, Chiu AS, Zhang Y, Pei KY. Characterization of High Mortality Probability Operations at National Surgical Quality Improvement Program Hospitals. JAMA Surg 2021; 155:85-88. [PMID: 31664436 DOI: 10.1001/jamasurg.2019.3750] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Benjamin J Resio
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Alexander S Chiu
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Yawei Zhang
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Kevin Y Pei
- Department of Surgery, Texas Tech University Health System, Lubbock
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14
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Chao GF, Emlaw J, Chiu AS, Yang J, Thumma J, Brackett A, Pei KY. Asian American Pacific Islander Representation in Outcomes Research: NSQIP Scoping Review. J Am Coll Surg 2021; 232:682-689.e5. [PMID: 33705984 DOI: 10.1016/j.jamcollsurg.2021.01.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 01/19/2021] [Accepted: 01/20/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND If Asian American and Pacific Islanders (AAPIs) are not recognized within patients in health services research, we miss an opportunity to ensure health equity in patient outcomes. However, it is unknown what the rates are of AAPIs inclusion in surgical outcomes research. STUDY DESIGN Through a scoping review, we used Covidence to search MEDLINE, EMBASE, PsycINFO, Web of Science, Scopus, and CINAHL for studies published in 2008-2018 using NSQIP data. NSQIP was chosen because of its national scope, widespread use in research, and coding inclusive of AAPI patients. We examined the proportion of studies representing AAPI patients in the demographic characteristics and Methods, Results, or Discussion section. We then performed multivariable logistic regression to examine associations between study characteristics and AAPI inclusion. RESULTS In 1,264 studies included for review, 62% included race. Overall, only 22% (n = 278) of studies included AAPI patients. Of studies that included race, 35% represented AAPI patients in some component of the study. We found no association between sample size or publication year and inclusion. Studies were significantly more likely to represent AAPI patients when there was a higher AAPI population in the region of the first author's institution (lowest vs highest tercile; p < 0.001). Studies with a focus on disparities were more likely to include AAPI patients (p = 0.001). CONCLUSIONS Our study is the first to examine AAPI representation in surgical outcomes research. We found < 75% of studies examine race, despite availability within NSQIP. Little more than one-third of studies including race reported on AAPI patients as a separate group. To provide the best care, we must include AAPI patients in our research.
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Affiliation(s)
- Grace F Chao
- National Clinician Scholars Program, Veterans Affairs Ann Arbor, Ann Arbor, MI; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI; Department of Surgery, New Haven, CT.
| | - Jonel Emlaw
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
| | | | - Jie Yang
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
| | - Jyothi Thumma
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
| | - Alexandria Brackett
- Harvey Cushing/John Hay Whitney Medical Library, Yale School of Medicine, New Haven, CT
| | - Kevin Y Pei
- Department of Surgery, Houston Methodist Hospital, Houston, TX
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Dickinson KJ, Bass BL, Pei KY. Public Perceptions of General Surgery Residency Training. J Surg Educ 2021; 78:717-727. [PMID: 33160942 DOI: 10.1016/j.jsurg.2020.09.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 08/13/2020] [Accepted: 09/28/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVE Patients are integral to surgical training. Understanding our patients' perceptions of surgical training, resident involvement and autonomy is crucial to optimizing surgical education and thus patient care. In the modern, connected world many factors extrinsic to a patient's experience of healthcare may influence their opinion of our training systems (i.e., social media, television shows, and internet searches). The purpose of this article is to contextualize the literature investigating public perceptions of general surgery training to allow us to effect patient education initiatives to optimize both surgical training and patient safety. DESIGN This is a perspective including a literature review summarizing the current knowledge of public perceptions of general surgery training. CONCLUSIONS Little is published regarding patient and public perceptions of general surgery residency training and the role of residents within this. Current literature demonstrates that the majority of patients are willing to have residents participate in their care. Patients' attitude toward resident involvement in their operation is improved by utilizing educational materials and by ensuring a supervising attending is present within the operating room. These observations, coupled with future work to delve deeper into factors affecting public perceptions of surgical training and resident involvement within this, can guide strategies to improve surgical education.
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Affiliation(s)
| | - Barbara L Bass
- George Washington University School of Medicine and Health Services, Washington, District of Columbia
| | - Kevin Y Pei
- Department of Graduate Medical Education, Parkview Health, Fort Wayne, Indiana
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Pei KY, Hafler J, Alseidi A, Slade MD, Klingensmith M, Cochran A. National Assessment of Workplace Bullying Among Academic Surgeons in the US. JAMA Surg 2021; 155:524-526. [PMID: 32236505 DOI: 10.1001/jamasurg.2020.0263] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
| | | | | | | | - Mary Klingensmith
- Department of Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Amalia Cochran
- Ohio State University Wexner Medical Center, Columbus.,Section Editor
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Adesoye T, Davis CH, Del Calvo H, Shaikh AF, Chegireddy V, Chan EY, Martinez S, Pei KY, Zheng F, Tariq N. "Optimization of Surgical Resident Safety and Education During the COVID-19 Pandemic - Lessons Learned". J Surg Educ 2021; 78:315-320. [PMID: 32739443 PMCID: PMC7328568 DOI: 10.1016/j.jsurg.2020.06.040] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 06/23/2020] [Accepted: 06/28/2020] [Indexed: 05/12/2023]
Abstract
The COVID-19 pandemic has engendered rapid and significant changes in patient care. Within the realm of surgical training, the resultant reduction in clinical exposure and case volume jeopardizes the quality of surgical training. Thus, our general surgery residency program proceeded to develop a tailored approach to training that mitigates impact on resident surgical education and optimizes clinical exposure without compromising safety. Residents were engaged directly in planning efforts to craft a response to the pandemic. Following the elimination of elective cases, the in-house resident complement was effectively decreased to reduce unnecessary exposure, with a back-up pool to address unanticipated absences and needs. Personal protective equipment availability and supply, the greatest concern to residents, has remained adequate, while being utilized according to current guidelines. Interested residents were given the opportunity to work in designated COVID ICUs on a volunteer basis. With the decrease in operative volume and clinical duties, we shifted our educational focus to an intensive didactic schedule using a teleconferencing platform and targeted areas of weakness on prior in-service exams. We also highlighted critical COVID-19 literature in a weekly journal club to better understand this novel disease and its effect on surgical practice. The long-term impact of the COVID-19 pandemic on resident education remains to be seen. Success may be achieved with commitment to constant needs assessment in the changing landscape of healthcare with the goal of producing a skilled surgical workforce for public service.
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Affiliation(s)
- T Adesoye
- Department of Surgery, Houston Methodist Hospital, Houston, Texas.
| | - C H Davis
- Department of Surgery, Houston Methodist Hospital, Houston, Texas
| | - H Del Calvo
- Department of Surgery, Houston Methodist Hospital, Houston, Texas
| | - A F Shaikh
- Department of Surgery, Houston Methodist Hospital, Houston, Texas
| | - V Chegireddy
- Department of Surgery, Houston Methodist Hospital, Houston, Texas
| | - E Y Chan
- Department of Surgery, Houston Methodist Hospital, Houston, Texas
| | - S Martinez
- Department of Surgery, Houston Methodist Hospital, Houston, Texas
| | - K Y Pei
- Department of Surgery, Houston Methodist Hospital, Houston, Texas
| | - F Zheng
- Department of Surgery, Houston Methodist Hospital, Houston, Texas
| | - N Tariq
- Department of Surgery, Houston Methodist Hospital, Houston, Texas
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Dickinson KJ, Bass BL, Graviss EA, Nguyen DT, Pei KY. Public perceptions of general surgery resident training and assessment. Surgery 2020; 169:830-836. [PMID: 33243485 DOI: 10.1016/j.surg.2020.10.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 10/07/2020] [Accepted: 10/16/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Patients play a crucial role in surgical training, but little is known about the public's knowledge of general surgery training structure or opinion of resident assessment. Our aim was to evaluate the public's knowledge of general surgery training and assessment processes. METHODS We administered an anonymous, electronic survey to US adult panelists using SurveyGizmo. We used Dillman's Tailored Design Method to optimize response rate. Questions pertained to demographics, knowledge of general surgery training structure, and opinions regarding resident assessment. Outcome measures included public knowledge of the structure of general surgery residency and the perceptions of resident assessment. Univariate and multivariate statistics were used as appropriate. RESULTS Survey response rate was 93% (2005 of 2148). Respondents had nationally representative demographics. Most respondents had health insurance (87%). Sixty-one percent of respondents believed that 100% of hospitals trained residents. Age <40 years, Black race (odds ratio 1.48 [95% confidence interval (CI) 1.11-1.96]), working in a hospital/health care field (odds ratio 1.49 [95% CI 1.12-1.97]), and having a family member/close acquaintance working in a hospital/health care field (odds ratio 1.53 [95% CI .20-1.94]) were associated with this belief. There was a preference to obtain online information about medical training (30% television [TV] shows, 24% Internet searches, 5% social media). Eighty percent of respondents felt that resident self-assessment and patient assessment of residents was "important" or "essential" when considering readiness for independent practice. CONCLUSION The US public has limited knowledge of general surgery training and competency assessment. Public educational strategies may help inform patients about the structure of training and assessment of trainees to improve engagement of these important stakeholders in surgical training.
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Affiliation(s)
| | - Barbara L Bass
- George Washington University School of Medicine and Health Services, Washington, DC
| | - Edward A Graviss
- Department of Surgery, Houston Methodist Hospital, TX; Department of Pathology and Genomic Medicine, Houston Methodist Hospital, TX
| | - Duc T Nguyen
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital, TX
| | - Kevin Y Pei
- Department of Graduate Medical Education, Parkview Health, IN
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Podrat JL, Del Val FR, Pei KY. Evolution of Risk Calculators and the Dawn of Artificial Intelligence in Predicting Patient Complications. Surg Clin North Am 2020; 101:97-107. [PMID: 33212083 DOI: 10.1016/j.suc.2020.08.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Risk calculators are an underused tool for surgeons and trainees when determining and communicating surgical risk. We summarize some of the more common risk calculators and discuss their evolution and limitations. We also describe artificial intelligence models, which have the potential to help clinicians better understand and use risk assessment.
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Affiliation(s)
- Jerica L Podrat
- Department of Surgery, Houston Methodist Hospital, 6550 Fannin Street, Suite SM1661, Houston, TX 77030, USA
| | - Fernando Ramirez Del Val
- Department of Surgery, Houston Methodist Hospital, 6550 Fannin Street, Suite SM1661, Houston, TX 77030, USA
| | - Kevin Y Pei
- Parkview Health GME, 2200 Randallia Drive, Administration, Fort Wayne, IN 46805, USA.
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Klemen ND, Feingold PL, Hashimoto B, Gross CP, Pei KY. Mortality benefits of thromboprophylaxis - Authors' reply. Lancet Haematol 2020; 7:e783-e784. [PMID: 33091349 DOI: 10.1016/s2352-3026(20)30322-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 09/15/2020] [Indexed: 11/17/2022]
Affiliation(s)
- Nicholas D Klemen
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA.
| | - Paul L Feingold
- Department of Surgery, Brigham and Women's Hospital, Harvard University, Boston MA, USA
| | - Barry Hashimoto
- Division of Social Science, New York University Abu Dhabi, Saadiyat Island, United Arab Emirates
| | - Cary P Gross
- Department of Internal Medicine and Yale COPPER Center, Yale University School of Medicine, New Haven, CT, USA
| | - Kevin Y Pei
- Department of Surgery, Indiana University School of Medicine, Fort Wayne, IN, USA
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21
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Majdinasab EJ, Puckett Y, Pei KY. Increased in-hospital mortality and emergent cases in patients with stage IV cancer. Support Care Cancer 2020; 29:3201-3207. [PMID: 33094359 DOI: 10.1007/s00520-020-05837-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Accepted: 10/15/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Cancer patients in the USA are still being treated with aggressive, life-prolonging interventions. Palliative care services remain vastly underutilized despite surges in both quality and quantity of programs. We evaluated surgical outcomes of metastatic cancer patients to question whether palliative care may be a better option. STUDY DESIGN We queried the 2014 National Surgical Quality Improvement Program database (NSQIP) for patients with a diagnosis of malignancy (ICD 9 Codes 145.00 to 200.00). Cases were divided into metastatic and non-metastatic cancer. Demographic data including preoperative, intraoperative, and postoperative factors, as well as complications and comorbidities were compared between these two groups. Independent t testing was used to compare continuous variables. Chi-square testing was used to compare categorical variables. Multiple logistic regression was used to assess for predictors of mortality in metastatic cancer. RESULTS A total of 80,275 cancer patients were analyzed, 11.8% (9423) of whom had metastatic disease. In-hospital mortality rate was found to be 4 times higher among patients with metastatic cancer (2.1% vs. 0.5%; P = < 0.0001). Of those metastatic cancer patients that died while in hospital, 18.5% had an emergency surgery performed. After adjusting for confounders, dyspnea at rest/moderate exertion (OR 5.7/2.4; 95% CI 2.7/1.6 to 11.9/3.7; P < 0.0001) was found to be the most significant predictor of in hospital mortality in stage IV cancer patients. CONCLUSION Aggressive treatment in advanced cancer patients contributes to alarmingly high in-hospital mortality. Improved, deliberate communication of palliative care options with patients is exceedingly conducive to enhancing end-of-life cancer care.
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Affiliation(s)
- Elleana J Majdinasab
- School of Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Yana Puckett
- Department of Surgery, West Virgina University School of Medicine, 3200 MacCorkle Ave SE,, Charleston, WV, 25304, USA.
| | - Kevin Y Pei
- Department of Acute Care Surgery and Surgical Critical Care, Houston Methodist, Houston, TX, USA
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Dickinson KJ, Bass BL, Nguyen DT, Graviss EA, Pei KY. Public Perception of General Surgery Resident Autonomy and Supervision. J Am Coll Surg 2020; 232:8-15.e1. [PMID: 33022397 DOI: 10.1016/j.jamcollsurg.2020.08.764] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 08/03/2020] [Accepted: 08/31/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Despite patients being important stakeholders in surgical training, little is known about the public's perception of trainee participation in surgical care. This study evaluates the public's perception of surgical resident autonomy and supervision. STUDY DESIGN An anonymous electronic survey was sent to adult panelists older than 18 years in the US using SurveyGizmo. The design of the survey used Dillman's Tailored Design Method to optimize response rate. Participants completed surveys including demographic characteristics and perceptions toward general surgery resident autonomy. Univariable and multivariable analyses were used as appropriate. RESULTS Survey response rate was 93% (2,005 of 2,148). Demographic characteristics including age, gender, race or ethnicity, and highest level of education were nationally representative. Most respondents (87%) had health insurance. On multivariable logistic regression analysis, factors associated with participants who would never allow a resident to perform any portion of the operation include: female gender (odds ratio [OR] 1.58; 95% CI, 1.28 to 1.95), no health insurance (OR 1.38; 95% CI, 1.03 to 1.84), Black race (OR 1.82; 95% CI, 1.38 to 2.41), and Hispanic ethnicity (OR 1.49; 95% CI, 1.03 to 2.15). Participants who were younger than 50 years (OR 1.57; 95% CI, 1.24 to 1.98), male (OR 1.90; 95% CI, 1.56 to 2.32), of Black race (OR 1.45; 95% CI, 0.10 to 1.91), Hispanic ethnicity (OR 1.49; 95% CI, 1.05 to 2.11), working in healthcare (OR 2.18; 95% CI, 1.67 to 2.86), or insured (OR 1.46; 95% CI, 1.07 to 1.99) were more likely to believe that resident involvement increases complications. CONCLUSIONS Among survey participants broadly representing the US population, resident participation in operations is not universally accepted. Public perception of surgical resident autonomy and supervision is important, as GME continues to evolve to address readiness for independent practice.
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Affiliation(s)
| | - Barbara L Bass
- George Washington University School of Medicine and Health Services, Washington, DC
| | - Duc T Nguyen
- Department of Pathology and Genomic Medicine, Houston Methodist Research Institute, Houston, TX
| | - Edward A Graviss
- Department of Surgery, Houston Methodist Hospital, Houston, TX; Department of Pathology and Genomic Medicine, Houston Methodist Research Institute, Houston, TX
| | - Kevin Y Pei
- Department of Graduate Medical Education, Parkview Health, Fort Wayne, IN
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Dickinson KJ, Bass BL, Pei KY. What embodies an effective surgical educator? A grounded theory analysis of resident opinion. Surgery 2020; 168:730-736. [DOI: 10.1016/j.surg.2020.04.056] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 04/24/2020] [Accepted: 04/27/2020] [Indexed: 02/06/2023]
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Detz DJ, Podrat JL, Muniz Castro JC, Lee YK, Zheng F, Purnell S, Pei KY. Small bowel obstruction. Curr Probl Surg 2020; 58:100893. [PMID: 34130796 DOI: 10.1016/j.cpsurg.2020.100893] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 09/04/2020] [Indexed: 02/06/2023]
Affiliation(s)
| | | | | | - Yoon K Lee
- Houston Methodist Hospital, Houston, Texas
| | - Feibi Zheng
- Weill Cornell Medicine, Houston Methodist Hospital, Houston, Texas
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Dickinson KJ, Bass BL, Graviss EA, Nguyen DT, Pei KY. How learning preferences and teaching styles influence effectiveness of surgical educators. Am J Surg 2020; 221:256-260. [PMID: 32921405 DOI: 10.1016/j.amjsurg.2020.08.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 08/03/2020] [Accepted: 08/19/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Effective surgical educators have specific attributes and learner-relationships. Our aim was to determine how intrinsic learning preferences and teaching styles affect surgical educator effectiveness. METHODS We determined i) learning preferences ii) teaching styles and iii) self-assessment of teaching skills for all general surgery attendings. All general surgical residents in our program completed teaching evaluations of attendings. RESULTS Multimodal was the most common learning preference (20/28). Although the multimodal learning preference appears to be associated with more effective educators than kinesthetic learning preferences, the difference was not statistically significant (80.0% versus 66.7%, p = 0.43). Attendings with Teaching Style 5 were more likely to have a lower "professional attitude towards residents" score on SETQ assessment by residents (OR 0.33 (0.11, 0.96), p = 0.04). Attendings rated their own "communication of goals" (p < 0.001), "evaluation of residents" (p = 0.04) and "overall teaching performance" (p = 0.01) per STEQ domains as significantly lower than the resident's assessment of these cofactors. CONCLUSION Identification of factors intrinsic to surgical educators with high effectiveness is important for faculty development. Completion of a teaching style self-assessment by attendings could improve effectiveness.
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Affiliation(s)
- Karen J Dickinson
- Department of Surgery, Houston Methodist Hospital, Houston, TX, USA.
| | - Barbara L Bass
- George Washington University School of Medicine and Health Services, DC, USA
| | - Edward A Graviss
- Department of Surgery, Houston Methodist Hospital, Houston, TX, USA; Department of Pathology and Genomic Medicine, Houston Methodist Research Institute, Houston, TX, USA
| | - Duc T Nguyen
- Department of Pathology and Genomic Medicine, Houston Methodist Research Institute, Houston, TX, USA
| | - Kevin Y Pei
- Department of Graduate Medical Education, Parkview Health, IN, USA
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26
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Ullrich SJ, DeWane MP, Cheung M, Fleming M, Namugga MM, Fu W, Kurigamba G, Kabuye R, Mabweijano J, Galukande M, Ozgediz D, Pei KY. Development of an Operative Trauma Course in Uganda-A Report of a Three-Year Experience. J Surg Res 2020; 256:520-527. [PMID: 32799000 DOI: 10.1016/j.jss.2020.07.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 06/01/2020] [Accepted: 07/11/2020] [Indexed: 11/15/2022]
Abstract
BACKGROUND Trauma is a leading cause of morbidity and mortality in low-income countries. Improved health care systems and training are potential avenues to combat this burden. We detail a collaborative and context-specific operative trauma course taught to postgraduate surgical trainees practicing in a low-resource setting and examine its effect on resident practice. METHOD Three classes of second year surgical residents participated in trainings from 2017 to 2019. The course was developed and taught in conjunction with local faculty. The most recent cohort logged cases before and after the course to assess resources used during initial patient evaluation and operative techniques used if the patient was taken to theater. RESULTS Over the study period, 52 residents participated in the course. Eighteen participated in the case log study and logged 117 cases. There was no statistically significant difference in patient demographics or injury severity precourse and postcourse. Postcourse, penetrating injuries were reported less frequently (40 to 21% P < 0.05) and road traffic crashes were reported more frequently (39 to 60%, P < 0.05). There was no change in the use of bedside interventions or diagnostic imaging, besides head CT. Of patients taken for a laparotomy, there was a nonstatistically significant increase in the use of four-quadrant packing 3.4 to 21.7%) and a decrease in liver repair (20.7 to 4.3%). CONCLUSIONS The course did not change resource utilization; however, it did influence clinical decision-making and operative techniques used during laparotomy. Additional research is indicated to evaluate sustained changes in practice patterns and clinical outcomes after operative skills training.
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Affiliation(s)
- Sarah J Ullrich
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut.
| | - Michael P DeWane
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Maija Cheung
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Matthew Fleming
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Martha M Namugga
- Department of Surgery, Makerere University, Mulago Hospital, Kampala, Uganda
| | - Whitney Fu
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Gideon Kurigamba
- Department of Surgery, Makerere University, Mulago Hospital, Kampala, Uganda
| | - Ronald Kabuye
- Department of Surgery, Makerere University, Mulago Hospital, Kampala, Uganda
| | - Jackie Mabweijano
- Department of Surgery, Makerere University, Mulago Hospital, Kampala, Uganda
| | - Moses Galukande
- Department of Surgery, Makerere University, Mulago Hospital, Kampala, Uganda
| | - Doruk Ozgediz
- Department of Surgery, University of California San Francisco, San Francisco, California
| | - Kevin Y Pei
- Department of Surgery, Houston Methodist Hospital, Houston, Texas
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Pei KY. Commentary on "Refusal of surgery for colon cancer: Socioeconomic disparities and survival implications among US patients with resectable disease". Am J Surg 2020; 221:37-38. [PMID: 32660700 DOI: 10.1016/j.amjsurg.2020.06.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 06/22/2020] [Accepted: 06/23/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Kevin Y Pei
- ACS-AEI Simulation Fellowship, Houston Methodist Hospital, Weill Cornell Medicine, Department of Surgery, 6550 Fannin St., SM 1661, Houston, TX, 77030, USA.
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28
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Dickinson KJ, Bass BL, Pei KY. The Current Evidence for Defining and Assessing Effectiveness of Surgical Educators: A Systematic Review. World J Surg 2020; 44:3214-3223. [DOI: 10.1007/s00268-020-05617-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Maassel NL, Fleming MM, Luo J, Zhang Y, Pei KY. Model for End-Stage Liver Disease Sodium as a Predictor of Surgical Risk in Cirrhotic Patients With Ascites. J Surg Res 2020; 250:45-52. [PMID: 32018142 DOI: 10.1016/j.jss.2019.12.037] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 12/11/2019] [Accepted: 12/30/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND The Model for End-Stage Liver Disease Sodium (MELD-Na) incorporates hyponatremia into the MELD score and has been shown to correlate with surgical outcomes. The pathophysiology of hyponatremia parallels that of ascites, which purports greater surgical risk. This study investigates whether MELD-Na accurately predicts morbidity and mortality in patients with ascites undergoing general surgery procedures. MATERIALS AND METHODS We used the National Surgical Quality Improvement Program database (2005-2014) to examine the adjusted risk of morbidity and mortality of cirrhotic patients with and without ascites undergoing inguinal or ventral hernia repair, cholecystectomy, and lysis of adhesions for bowel obstruction. Patients were stratified by the MELD-Na score and ascites. Outcomes were compared between patients with and without ascites for each stratum using low MELD-Na and no ascites group as a reference. RESULTS A total of 30,391 patients were analyzed. Within each MELD-Na stratum, patients with ascites had an increased risk of complications compared with the reference group (low MELD-Na and no ascites): low MELD-Na with ascites odds ratio (OR) 4.33 (95% confidence interval [CI] 1.96-9.59), moderate MELD-Na no ascites OR 1.70 (95% CI 1.52-1.9), moderate MELD-Na with ascites OR 3.69 (95% CI 2.49-5.46), high MELD-Na no ascites OR 3.51 (95% CI 3.07-4.01), and high MELD-Na ascites OR 7.18 (95% CI 5.33-9.67). Similarly, mortality risk was increased in patients with ascites compared with the reference: moderate MELD-Na no ascites OR 3.55 (95% CI 2.22-5.67), moderate MELD-Na ascites OR 13.80 (95% CI 5.65-33.71), high MELD-Na no ascites OR 8.34 (95% CI 5.15-13.51), and high MELD-Na ascites OR 43.97 (95% CI 23.76-81.39). CONCLUSIONS MELD-Na underestimates morbidity and mortality risk for general surgery patients with ascites.
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Affiliation(s)
- Nathan L Maassel
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut.
| | - Matthew M Fleming
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Jiajun Luo
- Section of Surgical Outcomes and Epidemiology, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Yawei Zhang
- Section of Surgical Outcomes and Epidemiology, Department of Surgery, Yale School of Medicine, New Haven, Connecticut; Department of Environmental Health Sciences, Yale School of Public Health, New Haven, Connecticut
| | - Kevin Y Pei
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut; Department of Surgery, Weill Cornell Medical College, Houston Methodist Hospital, Houston, Texas
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Resio BJ, Jean R, Chiu AS, Pei KY. Association of Timing of Colostomy Reversal With Outcomes Following Hartmann Procedure for Diverticulitis. JAMA Surg 2019; 154:218-224. [PMID: 30476948 DOI: 10.1001/jamasurg.2018.4359] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Importance The Hartmann procedure (end colostomy) remains a common operation for diverticulitis requiring surgery. However, the timing of subsequent colostomy reversal remains widely varied, and the optimal timing remains unknown. Objective To investigate the association of the timing of colostomy reversal with operative outcomes. Design, Setting, and Participants This retrospective analysis of the Healthcare Cost and Utilization Project State Inpatient Databases for California, Florida and Maryland included patients with colostomy for diverticulitis linked to their colostomy reversal. Patients with readmissions between the index surgery and reversal were excluded, leaving a final cohort of 1660 patients. Data were collected from January 1, 2010, to December 31, 2016, and analyzed from December 1, 2017, through May 31, 2018. Exposures Patients were divided based on timing of colostomy reversal following the index surgery into early (45-110 days), middle (111-169 days), and late (≥170 days) reversal timing. Main Outcomes and Measures Primary outcomes of interest after reversal included mortality, morbidity, and readmissions and were compared among all groups using logistic regression adjusted for comorbidities and age. Results In total, 7165 patients with at least 1 year of follow-up were identified, and 2028 (28.3%) underwent reversal within 1 year. Of patients who underwent reversal within 1 year, 1660 had no readmissions before reversal (860 men [51.8%]; median age, 61 years [interquartile range {IQR}, 51-70 years]). The median time to reversal was 129 days (IQR, 99-182 days). On multivariable analysis, patient characteristics associated with early reversal included being 60 years or younger (odds ratio [OR], 1.31; 95% CI, 1.00-1.70; P = .0497), white race (OR, 1.32; 95% CI, 1.05-1.67; P = .02), and private insurance vs Medicaid (OR, 2.45; 95% CI, 1.67-3.60; P < .001). Mortality, transfusion, ileus, and major complications were not significantly different among the reversal timing groups. However, prolonged length of stay (OR, 1.62; 95% CI, 1.19-2.21; P = .002) and 90-day readmissions (OR, 1.61; 95% CI, 1.18-2.22; P = .003) were significantly more likely in the late vs early timing groups. Conclusions and Relevance Less than one-third of patients undergo colostomy reversal within 1 year after end colostomy for diverticulitis, and reversal timing is associated with socioeconomic disparities. In selected patients with an uncomplicated course, improved outcomes are associated with earlier reversal, and colostomy reversal is safe as early as 45 to 110 days after the initial procedure.
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Affiliation(s)
- Benjamin J Resio
- Section of Emergency General Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Raymond Jean
- Section of Emergency General Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Alexander S Chiu
- Section of Emergency General Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Kevin Y Pei
- Section of Emergency General Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
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Chiu AS, Jean RA, Resio B, Pei KY. Reply to: "Early postoperative death in extreme risk patients: A perspective on surgical futility". Surgery 2019; 167:518. [PMID: 31629540 DOI: 10.1016/j.surg.2019.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Accepted: 09/02/2019] [Indexed: 11/18/2022]
Affiliation(s)
| | - Raymond A Jean
- Department of Surgery, Yale School of Medicine, New Haven, CT
| | - Benjamin Resio
- Department of Surgery, Yale School of Medicine, New Haven, CT
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Pei KY, Richmond R, Dissanaike S. Surgical instrument standardization - A pilot cost consciousness curriculum for surgery residents. Am J Surg 2019; 219:295-298. [PMID: 31629464 DOI: 10.1016/j.amjsurg.2019.10.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 09/07/2019] [Accepted: 10/07/2019] [Indexed: 01/02/2023]
Abstract
INTRODUCTION Surgical cost is astronomical in the US and instrument standardization is one potential mechanism for cost savings. This study describes a core competency based, multidisciplinary curriculum and evaluates resident attitudes towards operating room equipment standardization. MATERIALS AND METHODS As part of a quality improvement initiative, surgery residents participated in an hour-long mixed curriculum consisting of brief didactics and small group exercises. Participants developed an equipment standardization plan for laparoscopic appendectomy and cholecystectomy. Participants also completed surveys to assess their attitudes towards 11 potential barriers to implementation as "improves, no change, or worsens". RESULTS Fifteen general surgery residents participated. In general, participants felt that standardization improves or does not change metrics including surgeon autonomy, resident training experience, and patient safety. CONCLUSION Our pilot curriculum addresses a gap in resident education about surgical cost. Residents generally regard equipment standardization as either improving or not changing hospital metrics.
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Affiliation(s)
- Kevin Y Pei
- Houston Methodist Hospital, Houston, TX, USA.
| | - Robyn Richmond
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Sharmila Dissanaike
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, TX, USA
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Chiu AS, Jean RA, Hoag JR, Freedman-Weiss M, Healy JM, Pei KY. Association of Lowering Default Pill Counts in Electronic Medical Record Systems With Postoperative Opioid Prescribing. JAMA Surg 2019; 153:1012-1019. [PMID: 30027289 DOI: 10.1001/jamasurg.2018.2083] [Citation(s) in RCA: 121] [Impact Index Per Article: 24.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Importance Reliance on prescription opioids for postprocedural analgesia has contributed to the opioid epidemic. With the implementation of electronic medical record (EMR) systems, there has been increasing use of computerized order entry systems for medication prescriptions, which is now more common than handwritten prescriptions. The EMR can autopopulate a default number of pills prescribed, and 1 potential method to alter prescriber behavior is to change the default number presented via the EMR system. Objective To investigate the association of lowering the default number of pills presented when prescribing opioids in an EMR system with the amount of opioid prescribed after procedures. Design, Setting, and Participants A prepost intervention study was conducted to compare postprocedural prescribing patterns during the 3 months before the default change (February 18 to May 17, 2017) with the 3 months after the default change (May 18 to August 18, 2017). The setting was a multihospital health care system that uses Epic EMR (Hyperspace 2015 IU2; Epic Systems Corporation). Participants were all patients in the study period undergoing 1 of the 10 most common operations and discharged by postoperative day 1. Intervention The default number of opioid pills autopopulated in the EMR when prescribing discharge analgesia was lowered from 30 to 12. Main Outcomes and Measures Linear regression estimating the change in the median number of opioid pills and the total dose of opioid prescribed was performed. Opioid doses were converted into morphine milligram equivalents (MME) for comparison. The frequency of patients requiring analgesic prescription refills was also evaluated. Results There were 1447 procedures (mean [SD] age, 54.4 [17.3] years; 66.9% female) before the default change and 1463 procedures (mean [SD] age, 54.5 [16.4] years; 67.0% female) after the default change. After the default change, the median number of opioid pills prescribed decreased from 30 (interquartile range, 15-30) to 20 (interquartile range, 12-30) per prescription (P < .001). The percentage of prescriptions written for 30 pills decreased from 39.7% (554 of 1397) before the default change to 12.9% (183 of 1420) after the default change (P < .001), and the percentage of prescriptions written for 12 pills increased from 2.1% (29 of 1397) before the default change to 24.6% (349 of 1420) after the default change (P < .001). Regression analysis demonstrated a decrease of 5.22 (95% CI, -6.12 to -4.32) opioid pills per prescription after the default change, for a total decrease of 34.41 (95% CI, -41.36 to -27.47) MME per prescription. There was no statistical difference in opioid refill rates (3.0% [4 of 135] before the default change vs 1.5% [2 of 135] after the default change, P = .41). Conclusions and Relevance Lowering the default number of opioid pills prescribed in an EMR system is a simple, effective, cheap, and potentially scalable intervention to change prescriber behavior and decrease the amount of opioid medication prescribed after procedures.
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Affiliation(s)
- Alexander S Chiu
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Raymond A Jean
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut.,National Clinician Scholars Program, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Jessica R Hoag
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Section of General Internal Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | | | - James M Healy
- Department of Pediatric Surgery, Connecticut Children's Medical Center, Hartford
| | - Kevin Y Pei
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
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Healy JM, Davis KA, Pei KY. Comparison of Internal Medicine and General Surgery Residents' Assessments of Risk of Postsurgical Complications in Surgically Complex Patients. JAMA Surg 2019; 153:203-207. [PMID: 29049425 DOI: 10.1001/jamasurg.2017.3936] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Affiliation(s)
- James M. Healy
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Kimberly A. Davis
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Kevin Y. Pei
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
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Merola J, Arnold B, Luks V, Ibarra C, Resio B, Davis KA, Pei KY. Prophylactic Ureteral Stent Placement vs No Ureteral Stent Placement During Open Colectomy. JAMA Surg 2019; 153:87-90. [PMID: 28973647 DOI: 10.1001/jamasurg.2017.3477] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Jonathan Merola
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Brian Arnold
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Valerie Luks
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | | | - Benjamin Resio
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Kimberly A Davis
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Kevin Y Pei
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
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Chiu AS, Jean RA, Resio B, Pei KY. Early postoperative death in extreme-risk patients: A perspective on surgical futility. Surgery 2019; 166:380-385. [DOI: 10.1016/j.surg.2019.05.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 04/22/2019] [Accepted: 05/08/2019] [Indexed: 10/26/2022]
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Steren B, Fleming M, Zhou H, Zhang Y, Pei KY. Predictors of Delayed Emergency Department Throughput Among Blunt Trauma Patients. J Surg Res 2019; 245:81-88. [PMID: 31404894 DOI: 10.1016/j.jss.2019.07.028] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 06/21/2019] [Accepted: 07/12/2019] [Indexed: 01/09/2023]
Abstract
BACKGROUND Delayed emergency department (ED) LOS has been associated with increased mortality and increased hospital length of stay (LOS) for various patient populations. Trauma patients often require significant effort in evaluation, workup, and disposition; however, patient and hospital characteristics associated with increased LOS in the ED for trauma patients remain unclear. METHODS The Trauma Quality Improvement Project database (2014-2016) was queried for all adult blunt trauma patients. Patients discharged from the ED to the operating room were excluded. Univariate and multivariable linear regression analysis was conducted to identify independent predictors of ED LOS, controlling for patient characteristics (age, gender, race, insurance status), hospital characteristics (teaching status, ACS trauma verification level, geographic region), abbreviated injury scale and comorbid status. RESULTS 412,000 patients met inclusion criteria for analysis. When controlling for covariates, an increase in age by 1 y resulted in 0.63 increased minutes in the ED (P < 0.001). In multivariable linear regression controlling for injury severity and comorbid conditions, non-white race groups, university status, and northeast region were associated with increased ED LOS. Black and Hispanic patients spent on average 41 and 42 more minutes, respectively, in the ED room when compared with white patients (P < 0.001). Patients seen at University hospitals spent 52 more minutes in the ED when compared with community hospitals, whereas patients at nonteaching hospitals spent 31 fewer minutes (P < 0.001). Patients seen in the Midwest spent the least amount of time in the ED, with patients in the South, West, and Northeast spending 45, 36, and 89 more minutes, respectively (P < 0.001). Non-Medicaid patients at level 1 trauma centers and those requiring intensive care admission had significantly decreased ED LOS. Medicaid patients took the longest to move through the ED with Medicare, BlueCross, and Private insurance outpacing them by 17, 23, and 23 min, respectively (P < 0.001). ACS level 1 trauma centers moved patients through the ED fastest, whereas ACS level II trauma centers and level III trauma centers moved patients through 50 and 130 min slower when compared with ACS level 1 trauma centers (P < 0.001). CONCLUSIONS ED LOS varied significantly by patient and hospital characteristics. Medicaid patients and those patients at university hospitals were associated with significantly higher ED LOS, whereas ACS trauma verification level status had strong correlation with ED LOS. These results may allow targeted quality improvement programs to enhance ED LOS.
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Affiliation(s)
- Benjamin Steren
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Matthew Fleming
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Haoran Zhou
- Yale University School of Medicine, Section of Surgical Outcomes and Epidemiology, New Haven, Connecticut
| | - Yawei Zhang
- Yale University School of Medicine, Section of Surgical Outcomes and Epidemiology, New Haven, Connecticut
| | - Kevin Y Pei
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut; Department of Surgery, Texas Tech University of Health Sciences Center, School of Medicine, Lubbock, Texas.
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Liu Z, Luo JJ, Pei KY, Khan SA, Wang XX, Zhao ZX, Yang M, Johnson CH, Wang XS, Zhang Y. Joint effect of pre-operative anemia and perioperative blood transfusion on outcomes of colon-cancer patients undergoing colectomy. Gastroenterol Rep (Oxf) 2019; 8:151-157. [PMID: 32280475 PMCID: PMC7136710 DOI: 10.1093/gastro/goz033] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Revised: 06/25/2019] [Accepted: 07/10/2019] [Indexed: 01/01/2023] Open
Abstract
Background Both pre-operative anemia and perioperative (intra- and/or post-operative) blood transfusion have been reported to increase post-operative complications in patients with colon cancer undergoing colectomy. However, their joint effect has not been investigated. The purpose of this study was to evaluate the joint effect of pre-operative anemia and perioperative blood transfusion on the post-operative outcome of colon-cancer patients after colectomy. Methods We identified patients from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database 2006-2016 who underwent colectomy for colon cancer. Multivariate logistic regression analysis was employed to assess the independent and joint effects of anemia and blood transfusion on patient outcomes. Results A total of 35,863 patients-18,936 (52.8%) with left-side colon cancer (LCC) and 16,927 (47.2%) with right-side colon cancer (RCC)-were identified. RCC patients were more likely to have mild anemia (62.7%) and severe anemia (2.9%) than LCC patients (40.2% mild anemia and 1.4% severe anemia). A total of 2,661 (7.4%) of all patients (1,079 [5.7%] with LCC and 1,582 [9.3%] with RCC) received a perioperative blood transfusion. Overall, the occurrence rates of complications were comparable between LCC and RCC patients (odds ratio [OR] = 1.01; 95% confidence interval [CI] = 0.95-1.07; P = 0.750). There were significant joint effects of anemia and transfusion on complications and the 30-day death rate (P for interaction: 0.010). Patients without anemia who received a transfusion had a higher risk of any complications (LCC, OR = 3.51; 95% CI = 2.55-4.85; P < 0.001; RCC, OR = 3.74; 95% CI = 2.50-5.59; P < 0.001), minor complications (LCC, OR = 2.54; 95% CI = 1.63-3.97; P < 0.001; RCC, OR = 2.27; 95% CI = 1.24-4.15; P = 0.008), and major complications (LCC, OR = 5.31; 95% CI = 3.68-7.64; P < 0.001; RCC, OR = 5.64; 95% CI = 3.61-8.79; P < 0.001), and had an increased 30-day death rate (LCC, OR = 6.97; 95% CI = 3.07-15.80; P < 0.001; RCC, OR = 4.91; 95% CI = 1.88-12.85; P = 0.001) than patients without anemia who did not receive a transfusion. Conclusions Pre-operative anemia and perioperative transfusion are associated with an increased risk of post-operative complications and increased death rate in colon-cancer patients undergoing colectomy.
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Affiliation(s)
- Zheng Liu
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Jia-Jun Luo
- Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Kevin Y Pei
- Department of Surgery, School of Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Sajid A Khan
- Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Xiao-Xu Wang
- Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Zhi-Xun Zhao
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ming Yang
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Caroline H Johnson
- Department of Environmental Health Sciences, Yale School of Public Health, New Haven, CT, USA
| | - Xi-Shan Wang
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yawei Zhang
- Department of Surgery, Yale School of Medicine, New Haven, CT, USA.,Department of Environmental Health Sciences, Yale School of Public Health, New Haven, CT, USA
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Luo J, Liu Z, Pei KY, Khan SA, Wang X, Yang M, Wang X, Zhang Y. The Role of Bowel Preparation in Open, Minimally Invasive, and Converted-to-Open Colectomy. J Surg Res 2019; 242:183-192. [PMID: 31085366 DOI: 10.1016/j.jss.2019.02.039] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Revised: 02/05/2019] [Accepted: 02/22/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND Bowel preparation before colectomy is considered an effective strategy to decrease postoperative complications. However, data regarding the effect of bowel preparation in patients undergoing minimally invasive colectomy are limited. The aim of this study was to investigate the role of different bowel preparation strategies in patients undergoing open, minimally invasive, and converted-to-open elective colectomies. METHODS We identified 39,355 patients who underwent elective colectomy from the American College of Surgeons National Surgical Quality Improvement Program colectomy-targeted database (2012-2016). Multivariate logistic regression models were used to assess the impact of different bowel preparation strategies on postoperative complications and mortality in three subapproach groups: open (n = 12,141), minimally invasive (n = 23,057), and converted to open (n = 4157). RESULTS Overall, a total of 10,066 (25.6%) patients received no preparation (NP), 11,646 (29.5%) mechanical bowel preparation (MBP) alone, 1664 (4.2%) antibiotic bowel preparation (ABP) alone, and 15,979 (40.6%) MBP + ABP. Compared with NP, MBP + ABP showed the strongest protective effects. MBP + ABP was associated with reduced risk of major complications (odds ratio [OR] = 0.60, 95% confidence interval [CI]: 0.55-0.66), infectious complications (OR = 0.50, 95% CI: 0.46-0.54), any complications (OR = 0.55, 95% CI: 0.51-0.60), 30-d mortality (OR = 0.68, 95% CI: 0.48-0.96), anastomotic leak (OR = 0.50, 95% CI: 0.43-0.58), and length of stay ≥ 4 d (OR = 0.64, 95% CI: 0.61-0.67) in overall population. These protective effects, except for 30-d mortality, were observed in open, minimally invasive, and converted-to-open groups. When the analysis was limited to robotic surgery only, MBP + ABP was only associated with reduced risk of major complications (OR = 0.61, 95% CI: 0.38-0.97) compared with NP. The protective effects remained similar over the study time period. CONCLUSIONS MBP + ABP is a preferred preoperative strategy in open, minimally invasive, and converted-to-open colectomy.
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Affiliation(s)
- Jiajun Luo
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Zheng Liu
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Kevin Y Pei
- Department of Surgery, School of Medicine, Texas Tech University Health Sciences Center, Lubbock, Texas
| | - Sajid A Khan
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Xiaoxu Wang
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Ming Yang
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xishan Wang
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
| | - Yawei Zhang
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut; Department of Environmental Health Sciences, Yale School of Public Health, New Haven, Connecticut.
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Abstract
BACKGROUND Falls are the leading source of injury and trauma-related hospital admissions for elderly adults in the USA. Elderly patients with a history of a fall have the highest risk of falling again, and the decision on whether to continue anticoagulation after a fall is difficult. To inform this decision, we evaluated the rate of recurrent falls and the impact of anticoagulation on outcomes. METHODS All patients of age ≥ 65 years and hospitalized for a fall in the first 6 months of 2013 and 2014 were identified in the nationwide readmission database, a nationally representative all-payer database tracking patient readmissions. Readmissions for a recurrent fall within 6 months, and mortality and bleeding injuries (intracranial hemorrhage, solid organ bleed, and hemothorax) during readmission were identified. Logistic regression evaluated factors associated with mortality on repeat falls. RESULTS Of the 331,982 patients admitted for a fall, 15,565 (4.7%) were admitted for a recurrent fall within 6 months. The median time to repeat fall was 57 days (IQR 19-111 days), and 9.0% (1406) of repeat fallers were on anticoagulation. The rate of bleeding injury was similar regardless of anticoagulation status (12.8 vs. 12.7% not on anticoagulation, p = 0.97); however, among patients with a bleeding injury, those on anticoagulation had significantly higher mortality (21.5 vs. 6.9% not on anticoagulation, p < 0.01). CONCLUSION Among patients hospitalized for a fall, 4.7% will be hospitalized for a recurrent fall within 6 months. Patients on anticoagulation with repeat falls do not have increased rates of bleeding injury but do have significantly higher rates of death with a bleeding injury. This information is essential to discuss with patients when deciding to restart their anticoagulation.
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Affiliation(s)
- Alexander S Chiu
- Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Raymond A Jean
- Department of Surgery, Yale School of Medicine, New Haven, CT, USA.,National Clinician Scholars Program, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Matthew Fleming
- Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Kevin Y Pei
- Section of General Surgery, Trauma and Surgical Critical Care, Department of Surgery, Yale School of Medicine, 330 Cedar Street, BB310, New Haven, CT, 06519, USA.
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Chiu AS, Pei KY, Jean RA. Mentoring Sideways-A Model of Resident-to-Resident Research Mentorship. J Surg Educ 2019; 76:1-3. [PMID: 30626526 DOI: 10.1016/j.jsurg.2018.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Revised: 05/21/2018] [Accepted: 05/27/2018] [Indexed: 06/09/2023]
Abstract
The traditional apprenticeship model of research mentorship, where residents pursue research projects directed by attending surgeons, may be ill-suited to optimize research innovation, productivity, and leadership experience. This is particularly true in an era of ever mounting demands of academic attending surgeons, easier availability of powerful clinical databases, and more residents beginning training with prior research experience and advanced degrees. To help makeup the gaps of traditional research mentorship, we propose a complementary peer-focused, "sideways mentorship" approach. This model revolves around a consortium of residents who develop their own research ideas, and obtain feedback and technical input from fellow residents. Such a model provides trainees more opportunities to explore their own ideas, become exposed to a wider range of disciplines, share technical knowledge and prior experience, and practice being mentors themselves. We believe sideways mentoring model can be successful in this changing research era, and is a valuable addition to the traditional research model and encourage educational programs to support efforts in establishing resident-run research collaborative.
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Affiliation(s)
- Alexander S Chiu
- Department of Surgery, Yale School of Medicine, New Haven Connecticut.
| | - Kevin Y Pei
- Department of Surgery, Yale School of Medicine, New Haven Connecticut
| | - Raymond A Jean
- Department of Surgery, Yale School of Medicine, New Haven Connecticut; National Clinician Scholars Program, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
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Fleming MM, Liu F, Luo J, Zhang Y, Pei KY. Predictors of 30 Day Readmission Following Percutaneous Cholecystostomy. J Surg Res 2019; 233:1-7. [DOI: 10.1016/j.jss.2018.07.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 05/24/2018] [Accepted: 07/02/2018] [Indexed: 12/29/2022]
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Ahle SL, Healy JM, Pei KY. Prediction of Postoperative Surgical Risk: A Needs Assessment for a Medical Student Curriculum. J Surg Educ 2019; 76:89-92. [PMID: 30100325 DOI: 10.1016/j.jsurg.2018.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Revised: 07/06/2018] [Accepted: 07/10/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE Medical students' abilities to predict postoperative complications and death are unknown. We hypothesize that medical students will lack confidence in determining surgical risk and will significantly overestimate surgical risk for post-operative morbidities and mortality. DESIGN Participants were invited to participate in an electronic, anonymous survey to assess their ability to predict surgical risk. The survey presented 7 complex clinical scenarios representative of a diverse general surgery practice. Participants were asked to assess the likelihood of different morbidities and mortality on a 0-100% scale, and predictions were compared to the ACS NSQIP risk calculator. SETTING Yale School of Medicine, New Haven, Connecticut; Tertiary medical center PARTICIPANTS: Third year medical students on their surgery clerkship as well as general surgery residents were invited to participate. RESULTS Most students were not confident about predicting postoperative complications (83.3%) or mortality (70.8%). Most students did not feel that the surgery clerkship adequately prepared them to assess surgical risk (69.6%). When compared to surgical residents for most presented cases (57% of cases), students and residents similarly overestimated postoperative morbidities and mortality. Estimates varied significantly, with wide 95% confidence intervals. Only 17% of NSQIP predicted estimates fell within the 95% confidence intervals. CONCLUSIONS Medical students overestimate morbidity and mortality following surgery in complex patients. Additionally, they lack confidence in their ability to predict surgical complications. A formal curriculum for risk prediction is needed for medical students.
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Affiliation(s)
- Samantha L Ahle
- Yale School of Medicine, Department of Surgery, New Haven, Connecticut
| | - James M Healy
- Yale School of Medicine, Department of Surgery, New Haven, Connecticut
| | - Kevin Y Pei
- Yale School of Medicine, Department of Surgery, New Haven, Connecticut.
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Peprah D, Chiu AS, Jean RA, Pei KY. Comparison of Outcomes Between Total Abdominal and Partial Colectomy for the Management of Severe, Complicated Clostridium Difficile Infection. J Am Coll Surg 2018; 228:925-930. [PMID: 30576799 DOI: 10.1016/j.jamcollsurg.2018.11.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2018] [Revised: 11/30/2018] [Accepted: 11/30/2018] [Indexed: 11/25/2022]
Abstract
BACKGROUND Patients with severe, complicated Clostridium difficile infection (CDI) may ultimately require a colectomy. Although associated with high morbidity and mortality, a total colectomy has been the mainstay of surgical treatment. However, small studies have suggested partial colectomy may provide equivalent outcomes. We compared the outcomes of partial and total colectomy for CDI in a nationwide database. STUDY DESIGN We performed a retrospective study using the American College of Surgeons National Surgical Quality Improvement Project (NSQIP). Patients with a primary diagnosis of Clostridium difficile colitis from 2007 to 2015, who underwent a total abdominal or partial colectomy, were analyzed. Postoperative mortality rate, complications, and length of stay were evaluated. Logistic regression controlling for patient and clinical factors evaluated the impact of type of operation performed. RESULTS There were 733 colectomies for CDI, of which 151 (20.6%) were partial colectomies. Patients with a partial colectomy had a slightly higher 30-day mortality rate (37.1%) compared with total abdominal colectomy patients (34.7%, p = 0.58). However, logistic regression controlling for patient factors demonstrated no statistically significant difference for partial colectomy in 30-day mortality (odds ratio [OR] 1.21, 95% CI 0.76 to 1.96) or complication rate (OR 0.92, 95% CI 0.51 to 1.62) compared with total colectomy. There was no difference in days to surgery (4.6 partial vs 5.0 total, p = 0.70). Total abdominal colectomy trended toward a longer postoperative stay (18.0 vs 15.1 days for partial, p = 0.08). CONCLUSIONS In a national database, a significant percentage of operations for CDI are partial colectomies. There were no significant differences found in mortality or complications between partial and total colectomy for severe complicated CDI.
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Affiliation(s)
- David Peprah
- Department of Surgery, Yale School of Medicine, New Haven, CT
| | | | - Raymond A Jean
- Department of Surgery, Yale School of Medicine, New Haven, CT; National Clinician Scholars Program, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Kevin Y Pei
- Department of Surgery, Section of General Surgery, Trauma and Surgical Critical Care, Yale School of Medicine, New Haven, CT; Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, TX.
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Resio BJ, Pei KY, Liang J, Zhang Y. Evaluating the adoption of primary anastomosis with proximal diversion for emergent cases of surgically managed diverticulitis. Surgery 2018; 164:1230-1233. [DOI: 10.1016/j.surg.2018.06.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Revised: 05/29/2018] [Accepted: 06/05/2018] [Indexed: 11/30/2022]
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46
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Fleming MM, Liu F, Zhang Y, Pei KY. Model for End-Stage Liver Disease Underestimates Morbidity and Mortality in Patients with Ascites Undergoing Colectomy. World J Surg 2018. [PMID: 29541825 DOI: 10.1007/s00268-018-4591-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The Model for End-Stage Liver Disease (MELD) score and ascites correlate with surgical morbidity and mortality. However, the MELD score does not account for ascites. We sought to evaluate whether the MELD score accurately risk stratifies patients with ascites. METHODS We analyzed the American College of Surgeons National Surgical Quality Improvement Program (2005-2014) to examine the risk-adjusted morbidity and mortality of cirrhotic patients with and without ascites undergoing colectomy for diverticulitis. Patients were stratified by MELD score, and the presence of ascites and outcomes were compared between patients with and without ascites to the reference group of low MELD and no ascites. Multivariable logistic regression was used to control for demographic factors and comorbidities. RESULTS A total of 16,877 colectomies were analyzed. For each MELD stratum, patients with ascites have increased risk of complications compared to those without ascites (P < 0.05 unless indicated): low MELD ascites OR 1.13, P = 0.69, moderate MELD no ascites OR 1.37, moderate MELD ascites OR 2.06, high MELD no ascites OR 1.93, and high MELD ascites OR 3.54. These trends hold true for mortality: low MELD ascites OR 2.91, P = 0.063, moderate MELD no ascites OR 1.47, moderate MELD ascites OR 5.62, high MELD no ascites OR 3.04, and high MELD ascites OR 9.91. CONCLUSION Ascites predicts an increased risk for postoperative morbidity and mortality for cirrhotic patients undergoing colectomy for all MELD classifications. These findings suggest that the MELD score significantly underestimates postoperative risk as it does not account for ascites.
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Affiliation(s)
- Matthew M Fleming
- Section of General Surgery, Trauma, and Surgical Critical Care, Department of Surgery, Yale School of Medicine, 330 Cedar Street, BB310, New Haven, CT, 06519, USA
| | - Fangfang Liu
- Section of Surgical Outcomes and Epidemiology, Department of Surgery, Yale School of Medicine, New Haven, CT, USA.,, Beijing 302 Hospital, Beijing, China
| | - Yawei Zhang
- Section of Surgical Outcomes and Epidemiology, Department of Surgery, Yale School of Medicine, New Haven, CT, USA.,Department of Environmental Health Sciences, Yale School of Public Health, New Haven, CT, USA
| | - Kevin Y Pei
- Section of General Surgery, Trauma, and Surgical Critical Care, Department of Surgery, Yale School of Medicine, 330 Cedar Street, BB310, New Haven, CT, 06519, USA.
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Luks VL, Merola J, Arnold BN, Ibarra C, Pei KY. Prophylactic Ureteral Stenting in Laparoscopic Colectomy: Revisiting Traditional Practice. J Surg Res 2018; 234:161-166. [PMID: 30527469 DOI: 10.1016/j.jss.2018.09.041] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 07/28/2018] [Accepted: 09/12/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND Prophylactic placement of ureteral stents is performed during open colectomy to aid in ureteral identification and to enhance detection of injury. The effects of this practice in laparoscopic colectomy are unknown. This study compares outcomes of patients undergoing laparoscopic colectomy with and without prophylactic ureteral stenting. METHODS A retrospective cohort study at a tertiary academic medical center was performed. The primary outcome measure was the incidence of ureteral injury. Secondary outcomes evaluated included mortality, length of stay, procedural duration, and new-onset urinary complication (hematuria, dysuria, and urinary tract infection). RESULTS In 702 consecutive patients undergoing elective laparoscopic colectomy from 2013 to 2016, prophylactic stents were placed in 261 (37%) patients. Two ureteral injuries occurred (0.3%), both in patients who underwent ureteral stent placement (P = 0.07) and were found and repaired intraoperatively. There was no in-hospital mortality. When accounting for age-adjusted Charlson comorbidity score, procedural indication, gender, BMI, and extent of resection, no difference in hospital length of stay (P = 0.79) was noted comparing patients with and without stenting. However, stent placement prolonged operating time (P = 0.03) and increased the risk of new-onset urinary complications (P = 0.04). CONCLUSIONS In this study, ureteral injuries only occurred in those with stent placement. Prophylactic ureteral stents in laparoscopic colectomy are associated with increased operative time and urologic morbidity. Owing to the low prevalence of ureteral injury in the elective setting and the increased risk of urinary complications, use of prophylactic ureteral stenting should be highly selective.
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Affiliation(s)
- Valerie L Luks
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Jonathan Merola
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Brian N Arnold
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | | | - Kevin Y Pei
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut.
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Nicolson NG, Pei KY. Cost-Effectiveness of Early CT in Suspected Pulmonary Embolism in Trauma Patients: A Decision-Analytical Model. J Am Coll Surg 2018. [DOI: 10.1016/j.jamcollsurg.2018.07.302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Chiu AS, Ahle SL, Freedman-Weiss MR, Yoo PS, Pei KY. The impact of a curriculum on postoperative opioid prescribing for novice surgical trainees. Am J Surg 2018; 217:228-232. [PMID: 30180937 DOI: 10.1016/j.amjsurg.2018.08.007] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Revised: 06/22/2018] [Accepted: 08/11/2018] [Indexed: 01/27/2023]
Abstract
BACKGROUND Surgical residents are frequently responsible for prescribing postoperative analgesia, yet the vast majority are never formally educated on the subject. METHODS A resident-led educational presentation on postoperative analgesia prescribing was provided to incoming surgical interns at a tertiary academic center. Pre- and post-surveys assessed comfort in prescribing postoperative analgesia. Following the educational intervention, opioid prescriptions during the interns' first two months were compared to that of the prior year's interns. RESULTS Education was provided to 31 interns. Prior to the session, few interns felt comfortable prescribing opioids (20%) or non-opioid analgesia (32%). After the session, 96% felt more comfortable prescribing opioids and 91% more comfortable prescribing multi-modal analgesia. Interns who received education prescribed an average of 127.8 Morphine Milligram Equivalents (MME) per prescription, compared to 208.5 MME by the prior year's interns (p < 0.01). CONCLUSION Education on postoperative analgesia targeting interns can be effective in preparing trainees in effective and judicious analgesic prescribing.
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Affiliation(s)
- Alexander S Chiu
- Department of Surgery, Yale School of Medicine, New Haven, CT, USA.
| | - Samantha L Ahle
- Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | | | - Peter S Yoo
- Section of Transplant Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Kevin Y Pei
- Section of Trauma, Critical Care, and Emergency General Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
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Jean RA, Chiu AS, O'Neill KM, Lin Z, Pei KY. The influence of sociodemographic factors on operative decision-making in small bowel obstruction. J Surg Res 2018; 227:137-144. [DOI: 10.1016/j.jss.2018.02.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Revised: 01/22/2018] [Accepted: 02/14/2018] [Indexed: 11/25/2022]
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