Assessment of Demographic Changes of Workforce Diversity in Otolaryngology, 2013 to 2022

Importance

Given the growth of minoritized groups in the US and the widening racial and ethnic health disparities, improving diversity remains a proposed solution in the field of otolaryngology. Evaluating current trends in workforce diversity may highlight potential areas for improvement.

Objective

To understand the changes in gender, racial, and ethnic diversity in the otolaryngology workforce in comparison with changes in the general surgery and neurosurgery workforces from 2013 to 2022.

Design, Setting, and Participants

This cross-sectional study used publicly available data from the Accreditation Council for Graduate Medical Education and the Association of American Medical Colleges for 2013 to 2022, and included medical students and trainees in all US medical residency programs and allopathic medical schools.

Main Outcomes and Measures

Average percentages of women, Black, and Latino trainees during 2 intervals of 5 years (2013-2017 and 2018-2022). Pearson χ2 tests compared demographic information. Normalized ratios were calculated for each demographic group in medical school and residency. Piecewise linear regression assessed linear fit for representation across time periods and compared rates of change.

Results

The study population comprised 59 865 medical residents (43 931 [73.4%] women; 6203 [10.4%] Black and 9731 [16.2%] Latino individuals; age was not reported). The comparison between the 2 study intervals showed that the proportions of women, Black, and Latino trainees increased in otolaryngology (2.9%, 0.7%, and 1.6%, respectively), and decreased for Black trainees in both general surgery and neurosurgery (-0.4% and -1.0%, respectively). In comparison with their proportions in medical school, Latino trainees were well represented in general surgery, neurosurgery, and otolaryngology (normalized ratios [NRs]: 1.25, 1.06, and 0.96, respectively); however, women and Black trainees remained underrepresented in general surgery, neurosurgery, and otolaryngology (women NRs, 0.76, 0.33, and 0.68; Black NRs, 0.63, 0.61, and 0.29, respectively). The percentage of women, Black, and Latino trainees in otolaryngology all increased from 2020 to 2022 (2.5%, 1.1%, and 1.1%, respectively). Piecewise regression showed positive trends across all 3 specialties.

Conclusions and Relevance

The findings of this cross-sectional study indicate a positive direction but only a modest increase of diversity in otolaryngology, particularly in the context of national demographic data. Novel strategies should be pursued to supplement existing efforts to increase diversity in otolaryngology.

Diversity, Equity, and Inclusion: A Current Analysis of General Surgery Residency Programs

BACKGROUND

Local, regional, and national diversity, equity, and inclusion (DEI) initiatives have been established to combat barriers to entry and promote retention in surgery residency programs. Our study evaluates changes in diversity in general surgery residency programs. We hypothesize that diversity trends have remained stable nationally and regionally.

MATERIALS AND METHODS

General surgery residents in all postgraduate years were queried regarding their self-reported sex, race, and ethnicity following the 2020 ABSITE. Residents were then grouped into geographic regions. Data were analyzed utilizing descriptive statistics, Kruskal-Wallis test, and chi-square analyses.

RESULTS

A total of 9276 residents responded. Nationally, increases in female residents were noted from 38.0 to 46.0% (P < .001) and in Hispanic or Latinx residents from 7.3 to 8.3% (P = .031). Across geographic regions, a significant increase in female residents was noted in the Northwest (51.9 to 58.3%, P = .039), Midwest (36.9 to 43.3%, P = .006), and Southwest (35.8 to 47.5%, P = .027). A significant increase in black residents was only noted in the Northwest (0 to 15.8%, P = .031). The proportion of white residents decreased nationally by 8.9% and in the Mid-Atlantic, Southeast, and Southwest between 5.5 and 15.9% (P < .05).

DISCUSSION

In an increasingly diverse society, expanding the numbers of underrepresented surgeons in training, and ultimately in practice, is a necessity. This study shows that there are region-specific increases in diversity, despite minimal change on a national level. This finding may suggest the need for region-specific DEI strategies and initiatives. Future studies will seek to evaluate individual programs with DEI plans and determine if there is a correlation to changing demographics.

Demographic Disparity in Use of Telemedicine for Ambulatory General Surgical Consultation During the COVID-19 Pandemic: Analysis of the Initial Public Health Emergency and Second Phase Periods

BACKGROUND

Surgical patients with limited digital literacy may experience reduced telemedicine access. We investigated racial/ethnic and socioeconomic disparities in telemedicine compared with in-person surgical consultation during the coronavirus disease 2019 (COVID-19) pandemic.

STUDY DESIGN

Retrospective analysis of new visits within the Division of General & Gastrointestinal Surgery at an academic medical center occurring between March 24 through June 23, 2020 (Phase I, Massachusetts Public Health Emergency) and June 24 through December 31, 2020 (Phase II, relaxation of restrictions on healthcare operations) was performed. Visit modality (telemedicine/phone vs in-person) and demographic data were extracted. Bivariate analysis and multivariable logistic regression were performed to evaluate associations between patient characteristics and visit modality.

RESULTS

During Phase I, 347 in-person and 638 virtual visits were completed. Multivariable modeling demonstrated no significant differences in virtual compared with in-person visit use across racial/ethnic or insurance groups. Among patients using virtual visits, Latinx patients were less likely to have video compared with audio-only visits than White patients (OR, 0.46; 95% CI 0.22-0.96). Black race and insurance type were not significant predictors of video use. During Phase II, 2,922 in-person and 1,001 virtual visits were completed. Multivariable modeling demonstrated that Black patients (OR, 1.52; 95% CI 1.12-2.06) were more likely to have virtual visits than White patients. No significant differences were observed across insurance types. Among patients using virtual visits, race/ethnicity and insurance type were not significant predictors of video use.

CONCLUSION

Black patients used telemedicine platforms more often than White patients during the second phase of the COVID-19 pandemic. Virtual consultation may help increase access to surgical care among traditionally under-resourced populations.

Beyond the revised cardiac risk index: Validation of the hospital frailty risk score in non-cardiac surgery

Frailty is an established risk factor for adverse outcomes following non-cardiac surgery. The Hospital Frailty Risk Score (HFRS) is a recently described frailty assessment tool that harnesses administrative data and is composed of 109 International Classification of Disease variables. We aimed to examine the incremental prognostic utility of the HFRS in a generalizable surgical population. Using linked administrative databases, a retrospective cohort of patients admitted for non-cardiac surgery between October 1st, 2008 and September 30th, 2019 in Alberta, Canada was created. Our primary outcome was a composite of death, myocardial infarction or cardiac arrest at 30-days. Multivariable logistic regression was undertaken to assess the impact of HFRS on outcomes after adjusting for age, sex, components of the Charlson Comorbidity Index (CCI), Revised Cardiac Risk Index (RCRI) and peri-operative biomarkers. The final cohort consisted of 712,808 non-cardiac surgeries, of which 55·1% were female and the average age was 53·4 +/- 22·4 years. Using the HFRS, 86.3% were considered low risk, 10·7% were considered intermediate risk and 3·1% were considered high risk for frailty. Intermediate and high HFRS scores were associated with increased risk of the primary outcome with an adjusted odds ratio of 1·61 (95% CI 1·50-1.74) and 1·55 (95% CI 1·38-1·73). Intermediate and high HFRS were also associated with increased adjusted odds of prolonged hospital stay, in-hospital mortality, and 1-year mortality. The HFRS is a minimally onerous frailty assessment tool that can complement perioperative risk stratification in identifying patients at high risk of short- and long-term adverse events.

The Emergency Surgery Score is a powerful predictor of outcomes across multiple surgical specialties: Results of a retrospective nationwide analysis

BACKGROUND

The Emergency Surgery Score was recently validated in a prospective multicenter study as an accurate predictor of mortality in emergency general surgery patients. The Emergency Surgery Score is easily calculated using multiple demographic, comorbidity, laboratory, and acuity of disease variables. We aimed to investigate whether the Emergency Surgery Score can predict 30-day postoperative mortality across patients undergoing emergency surgery in multiple surgical specialties.

METHODS

Our study is a retrospective cohort study using data from the national American College of Surgeons National Surgical Quality Improvement Program database (2007-2017). We included patients that underwent emergency gynecologic, urologic, thoracic, neurosurgical, orthopedic, vascular, cardiac, and general surgical procedures. The Emergency Surgery Score was calculated for each patient, and the correlation between the Emergency Surgery Score and 30-day mortality was assessed for each specialty using the c-statistics methodology.

RESULTS

Of 6,485,915 patients, 173,890 patients were included. The mean age was 60 years, 50.6% were female patients, and the overall mortality was 9.7%. The Emergency Surgery Score predicted mortality best in emergency gynecologic, general, and urologic surgery (c-statistics: 0.97, 0.87, 0.81, respectively). The Emergency Surgery Score predicted mortality moderately well in emergency thoracic, neurosurgical, orthopedic, and vascular surgery (c-statistics 0.73-0.79). For example, the mortality of gynecology patients with an Emergency Surgery Score of 5, 9, and 13 was 2%, 27%, and 50%, respectively. The Emergency Surgery Score performed poorly in cardiac surgery.

CONCLUSION

The Emergency Surgery Score accurately predicts mortality across patients undergoing emergency surgery in multiple surgical specialties, especially general, gynecologic, and urologic surgery. The Emergency Surgery Score can prove useful for perioperative patient counseling and for benchmarking the quality of surgical care.

Structures, processes and models of care for emergency general surgery in Ontario: a cross-sectional survey

BACKGROUND

Emergency general surgery (EGS) patients require urgent surgical evaluation and intervention for various conditions, such as infectious or obstructive diseases of the gastrointestinal tract. We aimed to characterize the structures and processes that are relevant to the delivery of EGS care across Ontario hospitals and to evaluate the availability of critical resources at hospitals with formal EGS models.

METHODS

Between August 2019 and July 2020, we conducted a cross-sectional survey of Ontario hospitals that offered urgent general surgery (defined as the ability to provide nonelective surgical intervention within 24 to 48 hours of presentation) to adults. People with intimate knowledge of their hospital's EGS program completed a Web-based or telephone survey characterizing the program's organizational structure and staffing, operating room availability, interventional radiology and interventional endoscopy availability, intensive care unit availability and staffing, and regional participation. Their responses were compiled and comparisons were made between hospitals with and without formal EGS models of care, as well as between hospitals based on size and academic status.

RESULTS

Of the 114 Ontario hospitals identified, 109 responded (95.6% response rate). A third (34.6%; n = 37/107) of hospitals had EGS models of care. Thirty-four of these (91.9%) were large (> 100-bed) institutions that would be likely to have increased resources. However, even for hospitals of similar size, those with EGS models had increased staffing levels compared to those without (clinical associates 17.6% [n = 3/17] v. 10.0% [n = 2/20]; nurse practitioners or physician assistants 27.8% [n = 5/18] v. 14.3% [n = 3/21]). They also had better access to diagnostic and interventional equipment (24/7 access to computed tomography 94.1% [n = 16/17] v. 69.2% [n = 18/26]), interventional radiology (88.9% [n = 16/18] v. 42.3% [n = 11/26]), endoscopy (100% [n = 18/18] v. 69.2% [n = 18/26]) and endoscopic retrograde cholangiopancreatography (77.8% [n = 14/18] v. 42.3% [n = 11/26]), as well as dedicated operating room time (72.2% [n = 13/18] v. 0% [n = 0/25]).

INTERPRETATION

The structures and processes available to care for patients requiring EGS in Ontario were highly variable between hospitals. Hospitals with formal EGS models were more likely to have access to key resources.

Assessment of Hospital Characteristics and Interhospital Transfer Patterns of Adults With Emergency General Surgery Conditions

IMPORTANCE

Although patients with emergency general surgery (EGS) conditions frequently undergo interhospital transfers, the transfer patterns and associated factors are not well understood.

OBJECTIVE

To examine whether patients with EGS conditions are consistently directed to hospitals with more resources and better outcomes.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study performed a network analysis of interhospital transfers among adults with EGS conditions from January 1 to December 31, 2016. The analysis used all-payer claims data from the 2016 Healthcare Cost and Utilization Project state inpatient and emergency department databases in 8 states. A total of 728 hospitals involving 85 415 transfers of 80 307 patients were included. Patients were eligible for inclusion if they were 18 years or older and had an acute care hospital encounter with a diagnosis of an EGS condition as defined by the American Association for the Surgery of Trauma. Data were analyzed from January 1, 2020, to June 17, 2021.

EXPOSURES

Hospital-level measures of size (total bed capacity), resources (intensive care unit [ICU] bed capacity, teaching status, trauma center designation, and presence of trauma and/or surgical critical care fellowships), EGS volume (annual EGS encounters), and EGS outcomes (risk-adjusted failure to rescue and in-hospital mortality).

MAIN OUTCOMES AND MEASURES

The main outcome was hospital-level centrality ratio, defined as the normalized number of incoming transfers divided by the number of outgoing transfers. A higher centrality ratio indicated more incoming transfers per outgoing transfer. Multivariable regression analysis was used to test the hypothesis that a higher hospital centrality ratio would be associated with more resources, higher volume, and better outcomes.

RESULTS

Among 80 307 total patients, the median age was 63 years (interquartile range [IQR], 50-75 years); 52.1% of patients were male and 78.8% were White. The median number of outgoing and incoming transfers per hospital were 106 (IQR, 61-157) and 36 (IQR, 8-137), respectively. A higher log-transformed centrality ratio was associated with more resources, such as higher ICU capacity (eg, >25 beds vs 0-10 beds: β = 1.67 [95% CI, 1.16-2.17]; P < .001), and higher EGS volume (eg, quartile 4 [highest] vs quartile 1 [lowest]: β = 0.78 [95% CI, 0-1.57]; P = .01). However, a higher log-transformed centrality ratio was not associated with better outcomes, such as lower in-hospital mortality (eg, quartile 4 [highest] vs quartile 1 [lowest]: β = 0.30 [95% CI, -0.09 to 0.68]; P = .83) and lower failure to rescue (eg, quartile 4 [highest] vs quartile 1 [lowest]: β = -0.50 [95% CI, -1.13 to 0.12]; P = .27).

CONCLUSIONS AND RELEVANCE

In this study, EGS transfers were directed to high-volume hospitals with more resources but were not necessarily directed to hospitals with better clinical outcomes. Optimizing transfer destination in the interhospital transfer network has the potential to improve EGS outcomes.

Characterizing the social media footprint of general surgery residency programs

Background

The medical community has increasingly embraced social media for a variety of purposes, including trainee education, research dissemination, professional networking, and recruitment of trainees and faculty. Platform choice and usage patterns appear to vary by specialty and purpose, but few studies comprehensively assess programs’ social media presence. Prior studies assessed general surgery departments’ Twitter use but omitted additional social media platforms and residency-specific accounts.

Objective

This study sought to broadly characterize the social media footprint of U.S. general surgery residency programs.

Methods

Using a protocolized search of program websites, social media platforms (Twitter, Facebook, Instagram, LinkedIn), and internet search, cross-sectional data on social media usage in March 2020 were collected for programs, their affiliated departments, their program directors (PDs), and their assistant/associate PDs (APDs).

Results

318 general surgery residency programs, 313 PDs, and 296 APDs were identified. 47.2% of programs had surgery-specific accounts on ≥1 platform. 40.2% of PDs and APDs had ≥1 account on Twitter and/or LinkedIn. Program type was associated with social media adoption and Twitter utilization, with lower usage among university-affiliated and independent programs (p<0.01).

Conclusions

Most general surgery residencies, especially non-university-based programs, lacked any department or residency accounts across Twitter, Facebook, and Instagram by March 2020. These findings highlight opportunities for increased social media engagement and act as a pre-pandemic baseline for future investigations of how the shift to virtual trainee education, recruitment, conferences, and clinical care affect social media use.

Medical expertise as a critical influencing factor on the length of stay in the ED: A retrospective cohort study

Overcrowding in the emergency departments (ED) is a significant issue associated with increased morbidity and mortality rates as well as decreased patient satisfaction. Length of stay (LOS) is both a cause and a result of overcrowding. In Israel, as there are few emergency medicine (EM) physicians, the ED team is supplemented with doctors from specialties including internal medicine, general surgery, orthopedics etc. Here we compare ED length of stay (ED-LOS), treatment time and decision time between EM physicians, internists and general surgeons.A retrospective cohort study was conducted examining the Emergency Department length of stay (ED-LOS) for all adult patients attending Sheba Medical Center ED, Israel, between January 1st, and December 31st, 2014. Using electronic medical records, data was gathered on patient age, sex, primary ED physician, diagnosis, eventual disposition, treatment time and disposition decision time. The primary outcome variable was ED-LOS relative to case physician specialty and level (ED, internal medicine or surgery; specialist or resident). Secondary analysis was conducted on time to treatment/ decision as well as ED-LOS relative to patient classification variables (internal medicine vs surgical diagnosis). Specialists were compared to specialists and residents to residents for all outcomes.Residents and specialists in either EM, internal medicine or general surgery attended 57,486 (51.50%) of 111,630 visits to Sheba Hospital's general ED. Mean ED-LOS was 4.12 ± 3.18 hours. Mean treatment time and decision time were 1.79 ± 1.82 hours, 2.84 ± 2.17 hours respectively. Amongst specialists, ED-LOS was shorter for EM physicians than for internal medicine physicians (mean difference 0.28 hours, 95% CI 0.14-0.43) and general surgeons (mean difference 0.63 hours, 95% CI 0.43-0.83). There was no statistical significance between residents when comparing outcomes.Increasing the number of EM specialists in the ED may support efforts to decrease ED-LOS, overcrowding and medical errors whilst increasing patient satisfaction and outcomes.

Analysis of Pediatric Surgery Using the National Healthcare Insurance Service Database in Korea: How Many Pediatric Surgeons Do We Need in Korea?

BACKGROUND

In the past, general surgeons (GSs) without a pediatric surgical subspecialty often performed surgery on children and, even now, GSs are performing many pediatric surgeries. We aimed to investigate the involvement of pediatric surgeons (PSs) and GSs in pediatric surgery, compare the outcomes of surgery in the neonatal intensive care unit (NICU), and estimate the appropriate PS workforce in Korea.

METHODS

We used surgical data from the National Health Insurance Service database that was collected from patients under the age of 19 years in hospitals nationwide from January 2002 to December 2017. In this database, we found 37 hospitals where PSs worked by using the index operation (congenital diaphragmatic hernia, esophageal atresia, hypertrophic pyloric stenosis, Hirschsprung's disease, abdominal wall defect, jejunoileal atresia, malrotation, anorectal malformation, and biliary atresia). It was assumed that the surgery in the 37 hospitals was performed by PS and that the surgery in other hospitals was performed by GS. Mortality was analyzed to compare the outcomes of acute abdominal surgery in the NICU. We estimated the number of PS currently needed in Korea for each situation under the assumption that PS would perform all operations for the index operation, main pediatric diseases (index operation + gastroesophageal reflux disease, choledochal cyst, inguinal hernia, and appendicitis), acute abdominal surgery in the NICU, and all pediatric surgeries. Additionally, we estimated the appropriate number of PS required for more advanced pediatric surgery in the future.

RESULTS

The number of pediatric surgeries from 2002 to 2017 increased by 124%. Approximately 10.25% of the total pediatric surgeries were performed by PSs, and the percentage of the surgery performed by PSs increased from 8.32% in 2002 to 15.92% in 2017. The percentage of index operations performed by PSs annually was 62.44% in average. It was only 47.81% in 2002, and increased to 88.79% in 2017. During the last 5 years of the study period, the average annual number of surgeries for main pediatric diseases was approximately 33,228. The ratio of the number of surgeries performed by PS vs. GS steadily increased in main pediatric diseases, however, the ratio of the number of surgery performed by PS for inguinal hernia and appendicitis remained low in the most recent years. The percentage of the number of acute abdominal surgery performed by PS in the NICU was 44% in 2002, but it had recently risen to 89.7%. After 30 days of birth, mortality was significantly lower in all groups that were operated on by PS, rather than GS, during the last 5 years. In 2019, 49 PSs who were under the age of 65 years were actively working in Korea. Assuming that all pediatric surgeries of the patients under the age of 19 years should be performed by PS, the minimum number of PS currently required was about 63 if they perform all of the index operations, the main pediatric surgery was about 209, the NICU operation was about 63, and the all pediatric surgeries was about 366. Additionally, it was determined that approximately 165 to 206 PS will be appropriate for Korea to implement more advanced pediatric surgery in the future.

CONCLUSION

The proportion of the pediatric surgery performed by PS rather than GS is increasing in Korea, but it is still widely performed by GS. PSs have better operative outcomes for acute abdominal surgery in the NICU than GSs. We believe that at least the index operation or the NICU operation should be performed by PS for better outcome, and that a minimum of 63 PSs are needed in Korea to do so. In addition, approximately 200 PSs will be required in Korea in order to manage main pediatric diseases and to achieve more advanced pediatric surgery in the future.

Racial and Ethnic Diversity Among Obstetrics and Gynecology, Surgical, and Nonsurgical Residents in the US From 2014 to 2019

This cross-sectional study examines racial and ethnic diversity among obstetrics and gynecology (OBGYN), surgical, and nonsurgical residents in the US.

Use of the spatial access ratio to measure geospatial access to emergency general surgery services in California

BACKGROUND

Emergency general surgery (EGS) encompasses a spectrum of time-sensitive and resource-intensive conditions, which require adequate and timely access to surgical care. Developing metrics to accurately quantify spatial access to care is critical for this field. We sought to evaluate the ability of the spatial access ratio (SPAR), which incorporates travel time, hospital capacity, and population demand in its ability to measure spatial access to EGS care and delineate disparities.

METHODS

We constructed a geographic information science platform for EGS-capable hospitals in California and mapped population location, race, and socioeconomic characteristics. We compared the SPAR to the shortest travel time model in its ability to identify disparities in spatial access overall and for vulnerable populations. Reduced spatial access was defined as >60 minutes travel time or lowest three classes of SPAR.

RESULTS

A total of 283 EGS-capable hospitals were identified, of which 142 (50%) had advanced resources. Using shortest travel time, only 166,950 persons (0.4% of total population) experienced prolonged (>60 minutes) travel time to any EGS-capable hospital, which increased to 1.05 million (2.7%) for advanced-resource centers. Using SPAR, 11.5 million (29.5%) had reduced spatial access to any EGS hospital, and 13.9 million (35.7%) for advanced-resource centers. Rural residents had significantly decreased access for both overall and advanced EGS services when assessed by SPAR despite travel times within the 60-minute threshold.

CONCLUSION

While travel time and SPAR showed similar overall geographic patterns of spatial access to EGS hospitals, SPAR identified a greater a greater proportion of the population as having limited access to care. Nearly one third of California residents experience reduced spatial access to EGS hospitals when assessed by SPAR. Metrics that incorporate measures of population demand and hospital capacity in addition to travel time may be useful when assessing spatial access to surgical services.

LEVEL OF EVIDENCE

Cross-sectional study, level VI.

Should Common Bile Duct Exploration for Choledocholithiasis Be a Specialist-Only Procedure?

Background: Common bile duct exploration (CBDE) is performed uncommonly. Issues surrounding its uptake in the laparoscopic era include perceived difficulty and lack of training. We aim to determine the success of CBDE performed by "specialist" and "nonspecialist" common bile duct (CBD) surgeons to determine whether there is a substantial difference in success and safety. Methods: A 10-year retrospective audit was performed of patients undergoing CBD exploration for choledocholithiasis. Northern Health maintains an on-call available "specialist" CBD surgeon roster to aid with CBDE. Results: Five hundred fifty-one patients were identified, of which 489/551 (88.7%) patients had stones successfully cleared. Specialists had a higher success rate (90.8% versus 82.6%, P = .008), associated with a longer surgical time. Method (transcystic or transductal), approach (laparoscopic or open), and indication for operation were similar between groups. There was no significant difference in complications. To be confident of a surgeon having an 80% success rate, 70 procedures over 10 years were required, however, an "in-control" 50% success rate may only require 1 procedure per year. Conclusion: While specialist CBDE surgeons have improved success rates, nonspecialist general surgeons also have a good and comparable success rate with an equivalent complication rate. With realistic annual targets, nonspecialist CBD surgeons should be encouraged to perform CBDE in centers without specialist support.

Association between Dysphagia and Surgical Outcomes across the Continuum of Frailty

This study examined the relationship between dysphagia and adverse outcomes across frailty conditions among surgical patients ≥50 years of age. A retrospective cohort analysis of surgical hospitalizations in the Healthcare Cost and Utilization Project's National Inpatient Sample among patients ≥50 years of age undergoing intermediate/high risk surgery not involving the larynx, pharynx, or esophagus. Of 3,298,835 weighted surgical hospitalizations, dysphagia occurred in 1.2% of all hospitalizations and was higher in frail patients ranging from 5.4% to 11.7%. Dysphagia was associated with greater length of stay, higher total costs, increased non-routine discharges, and increased medical/surgical complications among both frail and non-frail patients. Dysphagia may be an independent risk factor for poor postoperative outcomes among surgical patients ≥50 years of age across frailty conditions and is an important consideration for providers seeking to reduce risk in vulnerable surgical populations.

[The impact of COVID-19 on surgical waiting lists.]

OBJECTIVE

In Spain, the number of persons that are in a surgery waiting list as well as the available surgery resources, differ across autonomous communities. The pandemic generated by COVID-19 has increased these waiting lists. In this study two objectives were pursued: on the one hand, to determine which are the resources that are determining the number of persons that are in a surgery waiting list per 1,000 inhabitants; on the other hand, to estimate the impact that the current pandemic has on the latter.

METHODS

To estimate which are the resources that are having a greater impact on the waiting lists and to forecast the effect that the COVID-19 has on them, we use dynamic panel data models. The data on the surgery resources and on the waiting lists by autonomous communities is obtained from the Surveys on Health, Hospital Statistics and reports on waiting lists of the Ministry of Health, Consumption and Social Well Being and the Counsels. The sample period is 2012-2017 (last published year for surgery resources). In addition, a literature review is conducted and it shows the important and complexity of waiting list like a gestion tool of health system (Science, SciELO and Dialnet web data bases).

RESULTS

COVID-19 will increase the waiting lists by approximately 7.6% to 19.14%, depending on the autonomous community. Not all the available surgery resources have the same relevance nor an equal effect on the reduction of the waiting lists. The most significant resources are the beds and operating rooms per 1,000 inhabitants. The hospital expenditure is not so relevant.

CONCLUSIONS

The panel data models estimate the relation between the surgery resources and the waiting list. The latter is deemed complex and different across autonomous communities. In addition, these models allow to predict the expected increase in the waiting lists and are, thus, a useful instrument for their management.

Surgical Unmet Need in a Low-Income Area of a Metropolitan City in India: A Cross-Sectional Study

INTRODUCTION

We investigated the burden of surgical conditions, level of unmet needs and reasons for non-utilization of surgical services in a slum of Ahmedabad, India.

METHODS

A community-based cross-sectional study was carried out from August to December 2019. Inclusion criteria was age > 14 years; any type of injury/condition that requires surgery; subject has had surgery in last 1 year, and death information of family members. Data were stored and coded in Microsoft excel and exported to IBM SPSS statistics version 25 software for data analysis. Frequencies and proportions (categorical variable) are used to summarize utilization of surgical services and understanding surgical need. The Surgeons Overseas Assessment of Surgical was used to identify surgical met and unmet needs translated into local language. Open Data Kit software was used to install questionnaire in the "Tablet" to collect information and stress-free workflow in field.

RESULTS

Out of 10,330 population in 2066 households, 7914 were more than 14 years of age. 3.46% (n = 274) people needed surgery; 116 did not avail surgery and were categorized in "unmet need." Fifty percent of individuals with surgical needs had abdominal- or extremities-related problems followed by eyes surgery need (14%); back, chest and breast surgical need was 13.5%. Seventeen percent of participants with surgical needs had wounds related to injury or accident while 63% had wounds that were not related to injury. Almost all participants had gone to a physician to seek healthcare, however 42% did not avail surgical care needed for a variety of reasons. Forty-six percent of participants needing surgical care underwent major surgical procedure, while 11% had minor procedures. Financial reasons (34.5%) and lack of trust (35.3%) were major reasons for not availing surgical care.

CONCLUSIONS AND RELEVANCE

Ahmedabad is a relatively high income metropolitan city, has universally free health care and multiple healthcare facilities. Despite this, we have shown that there is significant unmet need for surgical procedures in the low-income population. A unique finding was that most patients sought a consultation but approximately 50% did not avail of the free surgical procedures under the universally free health care system in this city. We propose creation of community healthcare workers focused on surgical conditions.

Evaluating the Reliability and Validity Evidence of the RIME (Reporter-Interpreter-Manager-Educator) Framework for Summative Assessments Across Clerkships

PURPOSE

The ability of medical schools to accurately and reliably assess medical student clinical performance is paramount. The RIME (reporter-interpreter-manager-educator) schema was originally developed as a synthetic and intuitive assessment framework for internal medicine clerkships. Validity evidence of this framework has not been rigorously evaluated outside of internal medicine. This study examined factors contributing to variability in RIME assessment scores using generalizability theory and decision studies across multiple clerkships, thereby contributing to its internal structure validity evidence.

METHOD

Data were collected from RIME-based summative clerkship assessments during 2018-2019 at Virginia Commonwealth University. Generalizability theory was used to explore variance attributed to different facets through a series of unbalanced random-effects models by clerkship. For all analyses, decision (D-) studies were conducted to estimate the effects of increasing the number of assessments.

RESULTS

From 231 students, 6,915 observations were analyzed. Interpreter was the most common RIME designation (44.5%-46.8%) across all clerkships. Variability attributable to students ranged from 16.7% in neurology to 25.4% in surgery. D-studies showed the number of assessments needed to achieve an acceptable reliability (0.7) ranged from 7 in pediatrics and surgery to 11 in internal medicine and 12 in neurology. However, depending on the clerkship each student received between 3 and 8 assessments.

CONCLUSIONS

This study conducted generalizability- and D-studies to examine the internal structure validity evidence of RIME clinical performance assessments across clinical clerkships. Substantial proportion of variance in RIME assessment scores was attributable to the rater, with less attributed to the student. However, the proportion of variance attributed to the student was greater than what has been demonstrated in other generalizability studies of summative clinical assessments. Overall, these findings support the use of RIME as a framework for assessment across clerkships and demonstrate the number of assessments required to obtain sufficient reliability.

The reduction in clinical and surgical exposure of trainees during COVID-19 and its impact on their training

OBJECTIVE

To assess the impact of coronavirus disease on surgical training.

METHODS

The cross-sectional study was conducted at the General Surgery Department of Liaquat National Hospital, Karachi, from August 2019 to May 2020, and comprised surgical trainees from year 1 to 4. The subjects were interviewed and inquired about their opinion regarding the impact of coronavirus disease on their training. Data was prospectively collected in two equal phases of 5 months each, separating the phases on the basis of the application of preventive measures and changes relating to coronavirus disease. Data of cases from log books was divided into major and minor cases.

RESULTS

Of the 24 surgical trainees available, 18(75%) participated; 12(66.6%) females and 6(33.3%) males. There was a significant difference between the two phases, with the number of surgical case going down drastically in the second phase (p=0.005), affecting the training process.

CONCLUSIONS

Considering the ongoing pandemic, it may be worthwhile to look into the possibility of increasing the duration of training.

The impact of the COVID-19 pandemic on emergency general surgery: a retrospective study

BACKGROUND

The COVID-19 pandemic has affected healthcare systems worldwide. The effect of the pandemic on emergency general surgery patients remains unknown.

OBJECTIVE

To reveal the effects of the COVID-19 pandemic on mortality and morbidity among emergency general surgery cases.

DESIGN AND SETTING

Data on patients who were admitted to the emergency department of a tertiary hospital in Samsun, Turkey, and had consultations at the general surgery clinic were analyzed retrospectively.

METHODS

Our study included comparative analysis on two groups of patients who received emergency general surgery consultations in our hospital: during the COVID-19 pandemic period (Group 2); and on the same dates one year previously (Group 1).

RESULTS

There were 195 patients in Group 1 and 132 in Group 2 (P < 0.001). While 113 (58%) of the patients in Group 1 were women, only 58 (44%) were women in Group 2 (P = 0.013). Considering all types of diagnosis, there was no significant difference between the two groups (P = 0.261). The rates of abscess and delayed abdominal emergency diseases were higher in Group 2: one case (0.5%) versus ten cases (8%); P < 0.001. The morbidity rate was higher in Group 2 than in Group 1: three cases (1.5%) versus nine cases (7%); P = 0.016.

CONCLUSIONS

The COVID-19 pandemic has decreased the number of unnecessary nonemergency admissions to the emergency department, but has not delayed patients' urgent consultations. The pandemic has led surgeons to deal with more complicated cases and greater numbers of complications.

Impact of a global pandemic on surgical education and training- review, response, and reflection

The catastrophic effects of the coronavirus disease-2019 global pandemic have revolutionised human society. The unprecedented impact on surgical training needs to be analysed in detail to achieve an understanding of how to deal with similar situations arising in the foreseeable future. The challenges faced by the surgical community initiated with the suspension of clinical activities and elective practice, and included the lack of appropriate personal protective equipment, and the self-isolation of trainees and reassignment to coronavirus patient-care regions. Together, all these elements had deleterious effects on the psychological health of the professionals. Surgical training irrespective of specialty is equally affected globally by the pandemic. However, the global crisis inadvertently has led to a few constructive adaptations in healthcare systems, including the development of tele-clinics, virtual academic sessions and conferences, and increased usage of simulation. The current review article was planned to highlight the impact of corona virus disease on surgical training and institutions' response to the situation in order to continue surgical training, and lessons learnt from the pandemic.

Spine Surgery in Italy in the COVID-19 Era: Proposal for Assessing and Responding to the Regional State of Emergency

In December 2019, coronavirus disease 2019 (COVID-19) was discovered in Wuhan, Hubei province, from where it spread rapidly worldwide. COVID-19 characteristics (increased infectivity, rapid spread, and general population susceptibility) pose a great challenge to hospitals. Infectious disease, pulmonology, and intensive care units have been strengthened and expanded. All other specialties have been compelled to suspend or reduce clinical and elective surgical activities. The profound effects on spine surgery call for systematic approaches to optimizing the diagnosis and treatment of spinal diseases. Based on the experience of one Italian region, we draw an archetype for assessing the current and predicted level of stress in the health care system, with the aim of enabling hospitals to make better decisions during the pandemic. Further, we provide a framework that may help guide strategies for adapting surgical spine care to the conditions of epidemic surge.

Identifying common treatments from Electronic Health Records with missing information. An application to breast cancer

The aim of this paper is to analyze the sequence of actions in the health system associated with a particular disease. In order to do that, using Electronic Health Records, we define a general methodology that allows us to: (i) identify the actions in the health system associated with a disease; (ii) identify those patients with a complete treatment for the disease; (iii) and discover common treatment pathways followed by the patients with a specific diagnosis. The methodology takes into account the characteristics of the EHRs, such as record heterogeneity and missing information. As an example, we use the proposed methodology to analyze breast cancer disease. For this diagnosis, 5 groups of treatments, which fit in with medical practice guidelines and expert knowledge, were obtained.

Impact of the SARS-CoV-2 pandemic on emergency surgery services-a multi-national survey among WSES members

BACKGROUND

The SARS-CoV-2 pandemic is a major challenge for health care services worldwide. It's impact on oncologic therapies and elective surgery has been described recently, and the literature provides guidelines regarding appropriate elective patient treatment during the pandemic. However, the impact of SARS-CoV-2 pandemic on emergency surgery services has been poorly investigated up to now.

METHODS

A 17-item web survey had been distributed to emergency surgeons in June 2020 around the world, investigating the impact of SARS-CoV-2 pandemic on patients and septic diseases both requiring emergency surgery and the time-to-intervention in emergency surgery routine, as well as experiences with surgery in COVID-19 patients.

RESULTS

Ninety-eight collaborators from 31 countries responded to the survey. The majority (65.3%) estimated the impact of the SARS-CoV-2 pandemic on emergency surgical patient care as being strong or very strong. Due to the pandemic, 87.8% reported a decrease in the total number of patients undergoing emergency surgery and approximately 25% estimated a delay of more than 2 h in the time-to-diagnosis and another 2 h in the time-to-intervention. Fifty percent make structural problems with in-hospital logistics (e.g. transport of patients, closed normal wards etc.) mainly responsible for delayed emergency surgery and the frequent need (56.1%) for a triage of emergency surgical patients. 56.1% of the collaborators observed more severe septic abdominal diseases during the pandemic, especially for perforated appendicitis and severe septic cholecystitis (41.8% and 40.2%, respectively). 62.2% had experiences with surgery in COVID-19-infected patients.

CONCLUSIONS

The results of The WSES COVID-19 emergency surgery survey are alarming. The combination of an estimated decrease in numbers of emergency surgical patients and an observed increase in more severe septic diseases may be a result of the fear of patients from infection with COVID-19 and a consecutive delayed hospital admission and diagnosis. A critical delay in time-to-diagnosis and time-to-intervention may be a result of changes in in-hospital logistics and operating room as well as intensive care capacities. Both reflect the potentially harmful impact of SARS-CoV-2 pandemic on emergency surgery services.

The Association between Nursing Skill Mix and Mortality for Adult Medical and Surgical Patients: Protocol for a Systematic Review

Skill mix refers to the number and educational experience of nurses working in clinical settings. Authors have used several measures to determine the skill mix, which includes nurse-to-patient ratio and the proportion of baccalaureate-prepared nurses. Observational studies have tested the association between nursing skill mix and patient outcomes (mortality). To date, this body of research has not been subject to systematic review or meta-analysis. The aim of this study is to systematically review and meta-analyse observational and experimental research that tests the association between nursing skill mix and patient mortality in medical and surgical settings. We will search four key electronic databases—MEDLINE [OVID], EMBASE [OVID], CINAHL [EBSCOhost], and ProQuest Central (five databases)—from inception. Title, abstract, and full-text screening will be undertaken independently by at least two researchers using COVIDENCE review management software. We will include studies where the authors report an association between nursing skill mix and outcomes in adult medical and surgical inpatients. Extracted data from included studies will consist measures of nursing skill mix and inpatient mortality outcomes. A meta-analysis will be undertaken if there are at least two studies with similar designs, exposures, and outcomes. The findings will inform future research and workforce planning in health systems internationally.

General surgery and COVID-19: review of practical recommendations in the first pandemic phase

BACKGROUND

In March, 2020, the World Health Organization declared COVID-19 a pandemic. The absence of previous knowledge of COVID-19 has made decision-making difficult for all in health care, including surgical departments. We reviewed the management recommendations for surgical activity and changes to surgical practice, identifying concordances and discrepancies, based on the literature published in the early phase of the pandemic.

METHOD

We searched the electronic datasets, PubMed Database, Google, and Google Scholar, using the keywords "SARS-CoV-2", "COVID-19", "surgery", "recommendations", "guideline", and "triage". The search was limited to the first 2 months after the pandemic began and was closed on May 6, 2020.

RESULTS

Twenty papers were included in the analysis and their recommendations are divided into the following categories: 1. general aspects, such as maintaining the safety of health personnel and indications for surgery. 2. The preoperative phase, with recommendations about activating different care pathways for COVID-19 positive patients. 3. The operative phase, with recommendations about activating safety measures for aerosol-generating procedures. 4. The postoperative phase, with recommendations for managing operating theatres and patient transfers.

CONCLUSION

The recommendations proposed in the revised documents are considered good practices aimed at keeping patients and healthcare professionals safe. However, these recommendations must be contextualized in each individual hospital.

Emergency general surgery in a public hospital in Malaysia

INTRODUCTION

Patients undergoing emergency general surgery (EGS) are at risk for death and complications. Information on the burden of EGS is critical for developing strategies to improve the outcomes.

METHODS

In this retrospective cohort study, medical records of all general surgical operations in a public hospital were reviewed for the period 1st January 2017 to 31st December 2017. Data on patient demographics, operative workload, case mix, time of surgery and outcomes were analysed.

RESULTS

Of the 2960 general surgical operations that were performed in 2017, 1720 (58.1%) of the procedures were performed as emergencies. The mean age for the patients undergoing emergency general surgical procedures was 37.9 years (Standard Deviation, ±21.0), with male preponderance (57.5%). Appendicitis was the most frequent diagnosis for the emergency procedures (43%) followed by infections of the skin and soft tissues (31.6%). Disorders of the colon and rectum ranked as the third most common condition, accounting for 6.7% of the emergency procedures. Majority of emergency surgery (59.3%) took place after office hours and on weekends. Post-operative deaths and admissions to critical care facilities increased during EGS when compared to elective surgery, p<0.01.

CONCLUSIONS

EGS constitutes a major part of the workload of general surgeons and it is associated significant risk for death and post-operative complications. The burden of EGS must be recognised and patient care systems must evolve to make surgery safe and efficient.

A Long, Unnerving Road: Malpractice Claims Involving the Surgical Management of Thyroid and Parathyroid Disease

BACKGROUND

Given their profound emotional, physical, and financial toll on patients and surgeons, we studied the characteristics, costs, and contributing factors of thyroid and parathyroid surgical malpractice claims.

METHODS

Using the Controlled Risk Insurance Company Strategies' Comparative Benchmarking System database, representing ~30% of all US paid and unpaid malpractice claims, 5384 claims filed against general surgeons and otolaryngologists from 1995-2015 were reviewed to isolate claims involving the surgical management of thyroid and parathyroid disease. These claims were studied, and multivariable regression analysis was performed to identify factors associated with plaintiff payout.

RESULTS

One hundred twenty-eight thyroid and parathyroid surgical malpractice claims were isolated. The median time from alleged harm event to closure of a malpractice case was 39 months. The most common associated complications were bilateral recurrent laryngeal nerve (RLN) injury (n = 23) and hematoma (n = 18). Complications led to death in 18 cases. Patient payout occurred in 33% of claims (n = 42), and the median cost per claim was $277,913 (IQR $87,343-$783,663). On multivariable analysis, bilateral RLN injury was predictive of patient payout (OR 3.58, p = 0.03), while procedure, death, and surgeon specialty were not.

CONCLUSION

Though rare, malpractice claims related to thyroid and parathyroid surgery are costly, time-consuming, and reveal opportunities for early surgeon-patient resolution after poor outcomes.

Can Better Selection Tools Help Us Achieve Our Diversity Goals in Postgraduate Medical Education? Comparing Use of USMLE Step 1 Scores and Situational Judgment Tests at 7 Surgical Residencies

PURPOSE

Use of the United States Medical Licensing Examination (USMLE) for residency selection has been criticized for its inability to predict clinical performance and potential bias against underrepresented minorities (URMs). This study explored the impact of altering traditional USMLE cutoffs and adopting more evidence-based applicant screening tools on inclusion of URMs in the surgical residency selection process.

METHOD

Multimethod job analyses were conducted at 7 U.S. general surgical residency programs during the 2018-2019 application cycle to gather validity evidence for developing selection assessments. Unique situational judgment tests (SJTs) and scoring algorithms were created to assess applicant competencies and fit. Programs lowered their traditional USMLE Step 1 cutoffs and invited candidates to take their unique SJT. URM status (woman, racial/ethnic minority) of candidates who would have been considered for interview using traditional USMLE Step 1 cutoffs was compared with the candidate pool considered based on SJT performance.

RESULTS

A total of 2,742 general surgery applicants were invited to take an online SJT by at least 1 of the 7 programs. Approximately 35% of applicants who were invited to take the SJT would not have met traditional USMLE Step 1 cutoffs. Comparison of USMLE-driven versus SJT-driven assessment results demonstrated statistically different percentages of URMs recommended, and including the SJT allowed an average of 8% more URMs offered an interview invitation (P < .01).

CONCLUSIONS

Reliance on USMLE Step 1 as a primary screening tool precludes URMs from being considered for residency positions at higher rate than non-URMs. Developing screening tools to measure a wider array of candidate competencies can help create a more equitable surgical workforce.

Diabetes in day case general and vascular surgery: A multicentre regional audit

BACKGROUND

People with Diabetes Mellitus (DM) are at increased risk of postoperative complications if their HbA1C readings are not well controlled. In the UK, there are clear national guidelines requiring all people with DM to have HbA1C blood testing within 6months before undergoing surgery and that these readings should be below 69 mmol/mol if this is safe to achieve. The aim of this study was to determine whether hospitals in the region were compliant with the guidelines.

METHODS

Data were prospectively collected from seven hospitals across the East of England region from 1st October 2017 to 31st March 2018 (6 months) in all people with DM undergoing elective day case procedures in General and Vascular surgery for benign disease.

RESULTS

A total of 181 people with DM were included in the study, of whom 77.9% were male patients and the median age was 63 years. The three most commonly performed operations were laparoscopic cholecystectomy (20.9%, n = 38/181), inguinal hernia repair (20.4%, n = 37/181) and umbilical/para-umbilical hernia repair (11.0%, n = 20/181). In keeping with the national guidelines, only 86.7% (n = 157/181) of patients had an HbA1C tested within 6 months prior to their surgery date. Of the patients who had a preoperative HbA1C, 14 (n = 14/157, 8.9%) had an HbA1C ≥ 69 mmol/mol, and 12 (n = 12/14, 85.7%) of these proceeded to surgery without optimisation of their HbA1C.

CONCLUSION

A significant proportion of people with diabetes undergoing elective day case procedures in our region do not have HbA1C testing within 6 months of their procedure as recommended by the national guidelines. In patients who do have a high HbA1C, the majority still undergo surgery without adequate control of their DM. Greater awareness amongst healthcare workers and robust pathways are required for this vulnerable group of patients if we are to reduce the risk of developing postoperative complication rates.

Making Progress: The University of Hawai'i at Manoa's (UHM) Department of Surgery's Cross-Cultural Health Care Efforts from 2008-2018

In 2008 the University of Hawai'i at Manoa's (UHM) Department of Surgery introduced the concept of cross-cultural health care (aka cultural competency) to its faculty and trainees. Much work remains before the cultural efforts wellknown outside the department are embraced within, but it has been prioritized for curriculum development and research. An example of the department's efforts include the Cross-Cultural Health Care Research Collaborative, which was created as a forum for faculty who have an interest in cultural issues related to healthcare and healthcare delivery. Participants from 14 UHM departments and other organizations developed projects and mentored students, resulting in over ten peer-reviewed publications. A related effort is the JABSOM Cultural Competency Resource Guide, which is in its 7th edition and reflects JABSOM activities and those of its collaborators. Another highlight is the Biennial Cross-Cultural Health Care Conference: Collaborative and Multidisciplinary Interventions, with six conferences held since 2010, hosting attendees from 28 US Mainland states and 11 countries. Additionally, the department has been recognized as one of the first to develop a cultural standardized patient exam for surgical residents. These nationally-recognized efforts resulted in invitations to serve on the very first cultural competency panel at the American College of Surgeons Clinical Congress and as a consultant on the development of Brigham and Women's Hospital's Center for Surgery and Public Health's Provider Awareness and Cultural dexterity Toolkit for Surgeons (PACTS), a standardized curriculum for surgical residents. The department plans to continue its work on these projects and document outcomes.

Thirty years of Tunisian publication of «case reports» in General Surgery (1989-2018)

OBJECTIVE

To describe the bibliometric profile of Tunisian "case report" publications in general surgery over the last thirty years (1989-2018).

METHODS

This is a descriptive bibliometric study on "case reports", general surgery, Tunisian affiliation, indexed in the Medline database, between January 1, 1989 and December 31, 2018. The themes of Search articles were defined by referring to their major keywords used for their indexing.

RESULTS

During 30 years of study, Medline indexed 188 papers in "General Surgery" type "case reports", signed by 80 authors in first position and 71 authors in last position, belonging to ten academic specialties and 19 professional affiliations. These papers were published by 60 journals, including the Ugandan magazine "Pan African Medical Journal", which published 23% of these "case reports" alone. The number of major indexing keywords was 299 words, mainly "Echinococcosis", "Pancreatic Cancers" and "Echinococcosis of the liver", together accounting for 18.1% of articles.

CONCLUSION

The plethora of "case reports" in Tunisian general surgery publications over the last three decades was accompanied by a preferential edition in the journal "Pan Afr Med J" and a thematic focus on hydatid cysts and cancers pancreatic. Hence the importance of strengthening the capacity of Tunisian surgeons in research methodology and scientific medical writing.

The effect of gender on operative autonomy in general surgery residents

BACKGROUND

Despite an increasing number of women in the field of surgery, bias regarding cognitive or technical ability may continue to affect the experience of female trainees differently than their male counterparts. This study examines the differences in the degree of operative autonomy given to female compared with male general surgery trainees.

METHODS

A smartphone app was used to collect evaluations of operative autonomy measured using the 4-point Zwisch scale, which describes defined steps in the progression from novice ("show and tell") to autonomous surgeon ("supervision only"). Differences in autonomy between male and female residents were compared using hierarchical logistic regression analysis.

RESULTS

A total of 412 residents and 524 faculty from 14 general surgery training programs evaluated 8,900 cases over a 9-month period. Female residents received less autonomy from faculty than did male residents overall (P < .001). Resident level of training and case complexity were the strongest predictors of autonomy. Even after controlling for potential confounding factors, including level of training, intrinsic procedural difficulty, patient-related case complexity, faculty sex, and training program environment, female residents still received less operative autonomy than their male counterparts. The greatest discrepancy was in the fourth year of training.

CONCLUSION

There is a sex-based difference in the autonomy granted to general surgery trainees. This gender gap may affect female residents' experience in training and possibly their preparation for practice. Strategies need to be developed to help faculty and residents work together to overcome this gender gap.

Adrenalectomy: should urologists not be doing more?

PURPOSE

Adrenalectomy is an operation performed by both urologists and general surgeons; however, the majority are performed by general surgeons. We investigated whether there was a difference in outcomes based on surgical specialty performing the procedure. If no differences exist, an argument can be made that urologists should be doing more adrenalectomies.

METHODS

The National Surgical Quality Improvement Project (NSQIP) Participant Use File (PUF) was queried to extract all cases of adrenalectomies performed from 2011 to 2015. Current Procedural Technology (CPT) codes 60540 and 60650 were used. The data were stratified by surgical specialty performing the adrenalectomy (urology or general surgery). Our outcomes of interest included post-surgical complications, reoperations, 30-day readmission, mortality, and hospital length of stay.

RESULTS

A total of 3358 patients who underwent adrenalectomy between 2011 and 2015 were included. General surgeons performed 90% of these (n = 3012) and urologists performed 10% (n = 334). Differences in number of post-surgical complications, length of stay, rate of reoperation, 30-day readmission, and mortality were not statistically significant between general surgeons and urologists (p = 0.76, p = 0.29, p = 0.37, p = 0.98, and p = 0.59, respectively). Small complication rates disallowed multivariable analyses, but unadjusted rates for reoperation, presence of any post-operative complication, readmission within 30 days, and mortality were similar between specialties.

CONCLUSIONS

Surgical specialty did not make a difference in outcomes for patients undergoing adrenalectomy, despite a large disparity in the number of procedures performed by general surgeons versus urologists. Urologists should continue performing adrenalectomies and, given their familiarity with the retroperitoneum, perhaps perform more than is the current trend.

Assessment of Surgeon Variation in Adherence to Evidence-Based Recommendations for Treatment of Trigger Finger

IMPORTANCE

Stenosing tenosynovitis (trigger finger) affects approximately 2% of the population. Given the prevalence of trigger finger and rising health care costs, adherence to the cost-effective and evidence-based treatment algorithm will permit better outcomes and allocation of resources.

OBJECTIVES

To examine treatment patterns for trigger finger and to determine surgeon-level and patient-level factors that influence adherence to evidence-based treatment.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective population-based cohort study examined deidentified claims for treatment of trigger finger from a national insurance provider using the Clinformatics Data Mart database. Patients were included if they were 18 years or older and treated from January 1, 2002, through December 31, 2016 (excluding a washout period from July 1, 2008, until June 30, 2010), with a new diagnosis of single-digit trigger finger. Data were analyzed from December 21, 2018, through April 28, 2019.

EXPOSURES

Cost-effective and evidence-based research published in July 2009 for the treatment of trigger finger.

MAIN OUTCOMES AND MEASURES

After excluding the 1-year washout period on either side of July 1, 2009, adherence to the recommended treatment algorithm of 2 corticosteroid injections before surgical release of trigger finger was compared with practice before publication of research supporting this cost-effective and evidence-based approach.

RESULTS

In this analysis of 83 667 patients with trigger finger, 52 698 (63.0%) were women, and 20 045 (24.0%) had type 1 or 2 diabetes. Mean (SD) age was 61 (13) years. From 2002 to 2016, an overall increasing trend in adherence to the cost-effective and evidence-based approach to treatment was noted, with no significant increase in adherence in the postpublication era (67.5% vs 73.3%; P = .27). Substantial variation in adherence was observed at the surgeon level (intraclass correlation, 33%). Plastic surgeons had no change in adherence over time compared with orthopedic surgeons (odds ratio [OR], 1.00; 95% CI, 0.98-1.02; P = .90), whereas general surgeons had increased adherence (OR, 1.04; 95% CI, 1.02-1.06; P < .001). Higher-volume surgeons were also more adherent to these evidence-based recommendations (OR, 1.59; 95% CI, 1.53-1.65; P < .001).

CONCLUSIONS AND RELEVANCE

This study found substantial surgeon-level variation in adherence to evidence-based treatment of trigger finger. Surgeon specialty and volume were associated with differences in adherence. Efforts to understand surgeon barriers to implementation, regardless of physician specialty, appear to be necessary, and better implementation strategies may permit increased uptake of evidence-based treatment of trigger finger.

Isolated adrenal metastectomy has a low morbidity rate irrespective of performing surgical sub-specialty

INTRODUCTION

There has been growing use of adrenalectomy as a potentially curative treatment option for patients with oligometastatic disease to the adrenal gland. We sought to compare the perioperative outcomes of patients undergoing isolated adrenalectomy in the setting of disseminated cancer using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Furthermore, we examined the impact of performing surgical sub-specialty on outcomes.

MATERIALS AND METHODS

Data from the ACS-NSQIP database was obtained for patients between 2011 and 2016 who underwent adrenalectomy. Patients were stratified by the presence or absence of disseminated cancer. Univariate and multivariate regression analyses were performed to test for an association between the presence or absence of disseminated cancer and perioperative outcomes. The relationship between performing specialist and outcomes was also compared.

RESULTS

A total of 4,207 patients were identified, with 270 (6.4%) in the disseminated cancer group. There was no significant difference in perioperative outcomes between patients with disseminated cancer and without disseminated cancer. On multivariate analysis, neither the presence of disseminated cancer (p = 0.47) nor the surgical sub-specialty performing adrenalectomy (p = 0.52) were associated with an increased risk postoperative morbidity or mortality. Of note, there was a statistically significant increase in the number of adrenalectomies performed by urologists in the setting of disseminated cancer (19.3% versus 10.4%, p < 0.01).

CONCLUSIONS

Patients undergoing adrenalectomy in the setting of disseminated cancer did not have significantly worse perioperative outcomes compared to patients undergoing adrenalectomy for other indications. The adverse perioperative event rate was similar whether the operation was performed by a urologist or a general surgeon.

Higher Surgeon Procedure Volume Is Associated with Improved Hemodialysis Vascular Access Outcomes

The objective of this study was to examine the association between surgeon characteristics, procedural volume, and short-term outcomes of hemodialysis vascular access. A retrospective cohort study was performed using Medicare Part A and B data from 2007 through 2014 merged with American Medical Association Physician Masterfile surgeon data. A total of 29,034 procedures met the inclusion criteria: 22,541 (78%) arteriovenous fistula (AVF) and 6,493 (22%) arteriovenous graft (AVG). Of these, 13,110 (45.2%) were performed by vascular surgeons, 9,398 (32.3%) by general surgeons, 2,313 (8%) by thoracic surgeons, 1,517 (5.2%) by other specialties, and 2,696 (9.3%) were unknown. Every 10-year increase in years in practice was associated with a 6.9 per cent decrease in the odds of creating AVF versus AVG (P = 0.02). Surgeon characteristics were not associated with the likelihood of vascular access failure. Every 10-procedure increase in cumulative procedure volume was associated with a 5 per cent decrease in the odds of vascular access failure (P = 0.007). There was no association of provider characteristics or procedure volume with survival free of repeat AVF/AVG or TC placement at 12 months. A significant portion of the variability in likelihood of creating AVF versus AVG is attributable to the provider-level variation. Increase in procedure volume is associated with decreased odds of vascular access failure.

The impact of medical documentation assistants on process performance measures in a surgical emergency department

BACKGROUND

The administrative work of physicians, particularly documentation effort, consumes considerable time in surgical emergency departments. At the same time, the latter face an ever-growing influx of patients, leading to increasing waiting and flow times and thus patient dissatisfaction as well as overload of physicians and nurses. The deployment of medical documentation assistants, who specialize in and undertake documentation work currently performed by physicians, poses a solution to the problem. The goal of this study is to assess the impact of deploying medical documentation assistants on key performance indicators of a surgical emergency department, i.e. waiting and flow times of patients differentiated according to triage categories, utilization of physicians and time allocation of physicians.

METHODS

The underlying study has analysed the processes of the surgical emergency department of a major university medical centre and modelled them in a discrete event simulation. Data on patient arrivals as well as processing times in the X-ray department and the laboratory were obtained from the clinical information system, while processing times in the emergency department were recorded using time-motion studies. Though the emergency department currently does not deploy medical documentation assistants, the simulation model includes a variable number of such assistants.

RESULTS

The deployment of a medical documentation assistant frees up physician working time and decreases the waiting time and consequently the flow time of patients, in particular for standard and non-urgent patients. Adding additional documentation assistants leads to further improvements, however, with diminishing marginal returns. Under the assumption of medical documentation assistants being 35% more efficient than physicians in undertaking documentation work, one of the three physicians can be replaced in the analysed surgical emergency department with an average of 502 patient arrivals per week.

CONCLUSIONS

Medical documentation assistants are a viable way of improving the performance of surgical emergency departments. Depending on the goals of the hospital, medical documentation assistants can be used for an array of measures such as decreasing patients' waiting and flow times or increasing physicians' time spent on medical treatment.

Mining patient-specific and contextual data with machine learning technologies to predict cancellation of children's surgery

BACKGROUND

Last-minute surgery cancellation represents a major wastage of resources and can cause significant inconvenience to patients. Our objectives in this study were: 1) To develop predictive models of last-minute surgery cancellation, utilizing machine learning technologies, from patient-specific and contextual data from two distinct pediatric surgical sites of a single institution; and 2) to identify specific key predictors that impact children's risk of day-of-surgery cancellation.

METHODS AND FINDINGS

We extracted five-year datasets (2012-2017) from the Electronic Health Record at Cincinnati Children's Hospital Medical Center. By leveraging patient-specific information and contextual data, machine learning classifiers were developed to predict all patient-related cancellations and the most frequent four cancellation causes individually (patient illness, "no show," NPO violation and refusal to undergo surgery by either patient or family). Model performance was evaluated by the area under the receiver operating characteristic curve (AUC) using ten-fold cross-validation. The best performance for predicting all-cause surgery cancellation was generated by gradient-boosted logistic regression models, with AUC 0.781 (95% CI: [0.764,0.797]) and 0.740 (95% CI: [0.726,0.771]) for the two campuses. Of the four most frequent individual causes of cancellation, "no show" and NPO violation were predicted better than patient illness or patient/family refusal. Models showed good cross-campus generalizability (AUC: 0.725/0.735, when training on one site and testing on the other). To synthesize a human-oriented conceptualization of pediatric surgery cancellation, an iterative step-forward approach was applied to identify key predictors which may inform the design of future preventive interventions.

CONCLUSIONS

Our study demonstrated the capacity of machine learning models for predicting pediatric patients at risk of last-minute surgery cancellation and providing useful insight into root causes of cancellation. The approach offers the promise of targeted interventions to significantly decrease both healthcare costs and also families' negative experiences.

Evaluating Treatment Patterns for Small Cell Carcinoma of the Colon Using the National Cancer Database (NCDB)

OBJECTIVE(S)

The objective of this study was to characterize the clinicopathological prognostic factors and treatment patterns for small cell carcinoma (SCC) of the colon, a rare disease without standard treatment guidelines.

METHODS

We analyzed clinicopathological and treatment variables for 503 cases of histologically proven SCC colon entered into the National Cancer Database (NCDB) between 2004 and 2013. Survival curves were generated using Kaplan-Meier and compared by the log-rank test. Cox proportional hazard regression was used to control for covariates and evaluate the effect of different treatment modalities on overall survival.

RESULTS

Four hundred seventy-two (93.8%) patients had complete clinical staging information and were therefore included in our analysis. Of these patients, 149 (31.5%) had limited stage disease (LD) and 323 (68.4%) had extensive stage disease (ED) at presentation. Median overall survival (OS) for patients with ED was significantly lower than for those with LD (4.04 months vs. 21.82 months; p < 0.001). Multivariate Cox regression analysis showed administration of chemotherapy was associated with improved survival in patients with LD and ED (p = 0.026, p < 0.001) while surgery was not associated with improved survival in patients with LD or ED (p = 0.943, p = 0.630). Radiation therapy was associated with improved survival in patients with ED (p = 0.044).

CONCLUSIONS

SCC of the colon carries a poor prognosis, especially in patients presenting with metastatic disease. Surgery and chemotherapy are administered more frequently than radiation, and chemotherapy is associated with improved survival, unlike surgery.

Defining Barriers and Facilitators to Advancement for Women in Academic Surgery

IMPORTANCE

Sex equity is elusive in academic surgery departments across the United States. Persistent inequities remain a considerable problem and inhibit professional advancement for female surgeons. Identifying the factors that promulgate sex discrepancies may provide a framework for institutional growth and personal progress for women.

OBJECTIVE

To identify barriers and facilitators to success at the individual and organizational level to develop evidence-based interventions designed to close the sex gap in surgery.

DESIGN, SETTING, AND PARTICIPANTS

This qualitative study included 26 female participants who were current and former surgical faculty employed by Michigan Medicine, the health system of the University of Michigan, between 2000 and 2017. Semistructured personal interviews were conducted from June 28 to September 29, 2017, via telephone. Each interview lasted 45 minutes to 1 hour. Interviews were recorded and then transcribed for analysis.

MAIN OUTCOMES AND MEASURES

The interview included 7 questions referring to the surgeon's experience with the Michigan Medicine Department of Surgery and 7 questions referring to nonspecific areas of interest.

RESULTS

The 26 participants in this study ranged in age from 32 to 64 years, with faculty experience ranging from 3 to 22 years. Thematic analysis was used to locate, analyze, and report patterns within the data related to barriers and facilitators for women in academic medicine. Three major themes were identified by researchers. Participants reported that (1) organizational culture and institutional policies affect opportunities for advancement; (2) relational interactions with leadership, mentors, colleagues, and staff affect promotion and attrition; and (3) individual characteristics mediate the perception of professional and personal success.

CONCLUSIONS AND RELEVANCE

In this qualitative study of 26 female academic surgeons, a complex matrix of organizational and individual factors were found to contribute to sex inequities in academic surgery. This research may provide insight into the sex biases that inhibit advancement, may inform strategies that facilitate progress, and may inspire interventions that could help eliminate institutional and individual barriers to the academic success of women.

Development and Implementation of a Hands-on Surgical Pipeline Program for Low-Income High School Students

This qualitative study describes the development and implementation of a hands-on surgical pipeline program for low-income high school students.

Evolution of Workforce Diversity in Surgery✰

OBJECTIVE

Assessing workforce diversity over time is essential to understanding how it has evolved and anticipating its future. We conducted the current study to evaluate gender, racial/ethnic, and duty trends over the past decade in general surgery and surgical subspecialties.

DESIGN

This is a cross-sectional study. We calculated ratios and relative changes to assess potential differences of physicians' characteristics across time and surgical subspecialties.

SETTING

We evaluated data acquired by the Association of American Medical Colleges.

PARTICIPANTS

We extracted data from the 2000 to 2013 including the overall number of surgeons, surgeon race/ethnicity, gender, and primary professional activity.

RESULTS

During 2000 to 2013, the total number of surgeons increased 11.5%, reaching 172,062 active surgeons and residents, the majority of whom were White (64%) or male (75%). However, from 2000 to 2013, most specialties showed some improvement in terms of including minorities and females. Most surgeons (98%) participate in patient care while a small portion are devoted to other activities (e.g., administrative, research, teaching; 2%). Both groups increased over the study period.

CONCLUSIONS

Our findings suggest that the face of surgery is changing. Continuous monitoring of the surgical workforce is important to anticipate future needs and to serve a diverse patient population.

National Institute for Health Research Global Health Research Unit on Global Surgery. Prioritizing research for patients requiring surgery in low- and middle-income countries

BACKGROUND

The National Institute for Health Research Global Health Research Unit on Global Surgery is establishing research Hubs in low- and middle-income countries (LMICs). The aim of this study was for the Hubs to prioritize future research into areas of unmet clinical need for patients in LMICs requiring surgery.

METHODS

A modified Delphi process was overseen by the research Hub leads and engaged LMIC clinicians, patients and expert methodologists. A four-stage iterative process was delivered to prioritize research topics. This included anonymous electronic voting, teleconference discussions and a 2-day priority-setting workshop.

RESULTS

In stage 1, Hub leads proposed 32 topics across six domains: access to surgery, cancer, perioperative care, research methods, acute care surgery and communicable disease. In stages 2 and 3, 40 LMICs and 20 high-income countries participated in online voting, leading to identification of three priority research topics: access to surgery; outcomes of cancer surgery; and perioperative care. During stage 4, specific research plans to address each topic were developed by Hub leads at a priority-setting workshop.

CONCLUSION

This process identified three priority areas for future research relevant to surgery in LMICs. It was driven by front-line LMIC clinicians, patients and other stakeholders representing a diverse range of settings. The results of the prioritization exercise provide a future framework for researchers and funders.

Effect of in-hospital delays on surgical mortality for emergency general surgery conditions at a tertiary hospital in Malawi

Background

In sub‐Saharan Africa, surgical access is limited by an inadequate surgical workforce, lack of infrastructure and decreased care‐seeking by patients. Delays in treatment can result from delayed presentation (pre‐hospital), delays in transfer (intrafacility) or after arrival at the treating centre (in‐hospital delay; IHD). This study evaluated the effect of IHD on mortality among patients undergoing emergency general surgery and identified factors associated with IHD.

Methods

Utilizing Malawi's Kamuzu Central Hospital Emergency General Surgery database, data were collected prospectively from September 2013 to November 2017. Included patients had a diagnosis considered to warrant urgent or emergency intervention for surgery. Bivariable analysis and Poisson regression modelling was done to determine the effect of IHD (more than 24 h) on mortality, and identify factors associated with IHD.

Results

Of 764 included patients, 281 (36·8 per cent) had IHDs. After adjustment, IHD (relative risk (RR) 1·68, 95 per cent c.i. 1·01 to 2·78; P = 0·045), generalized peritonitis (RR 4·49, 1·69 to 11·95; P = 0·005) and gastrointestinal perforation (RR 3·73, 1·25 to 11·08; P = 0·018) were associated with a higher risk of mortality. Female sex (RR 1·33, 1·08 to 1·64; P = 0·007), obtaining any laboratory results (RR 1·58, 1·29 to 1·94; P < 0·001) and night‐time admission (RR 1·59, 1·32 to 1·90; P < 0·001) were associated with an increased risk of IHD after adjustment.

Conclusion

IHDs were associated with increased mortality. Increased staffing levels and operating room availability at tertiary hospitals, especially at night, are needed.

Social Belonging as a Predictor of Surgical Resident Well-being and Attrition

OBJECTIVE

In light of the predicted shortage of surgeons, attrition from surgical residency is a significant problem. Prior data have shown that those who are happier are more productive, and those who are less well have higher rates of absenteeism. This study sought to identify the role of social belonging and its relationship to well-being and risk of attrition.

DESIGN

Surgical residents were invited to participate in an online survey containing measures of social belonging (a 10-item scale adapted from previous studies), well-being (the Dupuy Psychological General Well-Being Scale, Beck Depression Inventory Short Form, and Maslach Burnout Inventory), and risk of attrition (indicated by frequency of thoughts of leaving the program).

SETTING

We surveyed residents at 2 tertiary care centers, Stanford Health Care (2010, 2011, and 2015) and Washington University in St. Louis (2017).

PARTICIPANTS

Categorical general surgery residents, designated preliminary residents going into 7 surgical subspecialties, and nondesignated preliminary residents were included.

RESULTS

One hundred sixty-nine residents responded to the survey for a response rate of 66%. Belonging was positively correlated with general psychological well-being (r = 0.56, p < 0.0001) and negatively correlated with depression (r = -0.57, p < 0.0001), emotional exhaustion (r = -0.58, p < 0.0001), and depersonalization (r = -0.36, p < 0.0001). Further, belonging was negatively correlated with frequency of thoughts of leaving residency (r = -0.45, p < 0.0001). In regression analysis controlling for demographic variables, belonging was a significant positive predictor of psychological well-being (B = 0.95, t = 8.18, p < 0.0001) and a significant negative predictor of thoughts of leaving (B = -1.04, t = -5.44, p < 0.0001).

CONCLUSIONS

Social belonging has a significant positive correlation with well-being and negative correlation with thoughts of leaving surgical training. Lack of social belonging appears to be a significant predictor of risk of attrition in surgical residency. Efforts to enhance social belonging may protect against resident attrition.