Variation in National ACGME Case Log Data for Pediatric Orthopaedic Fellowships: Are Fellow Coding Practices Responsible?

Nationwide Effect of COVID-19 on Cases Performed During Pediatric Orthopaedic Surgery Fellowship Training in the United States

INTRODUCTION

The COVID-19 pandemic negatively affected surgical training in the United States. We hypothesized that reported case volume during pediatric orthopaedic surgery fellowship training would decrease markedly during the 2019 to 2020 academic year, which corresponded with the COVID-19 outbreak.

METHODS

The Accreditation Council for Graduate Medical Education provided nationwide case logs for accredited pediatric orthopaedic surgery fellows (2017 to 2021). Annual reported case volumes were extracted and summarized as means ± SD. Parametric tests were used to compare annual case volumes.

RESULTS

A total of 149 pediatric orthopaedic fellows from 23 accredited fellowships were included. A 16% year-over-year (YoY) decrease was noted in the reported case volume during the 2019 to 2020 academic year (238 ± 80 vs. 255 ± 60, P < 0.001). Nonacute case categories had the most notable YoY percentage decreases: Soft Tissue: Transfer, Lengthen, Release (-42%); Clubfoot (-34%); and Foot and Ankle Deformity (-31%). Acute case categories had the most notable YoY percentage increases: Trauma Lower Limb (12%) and Trauma Upper Limb (10%). A subsequent 42% YoY increase was noted in the reported case volume during the 2020 to 2021 academic year.

DISCUSSION

A 16% YoY decrease was noted in the reported case volume during the 2019 to 2020 academic year, which corresponded to widespread economic shutdowns during the initial COVID-19 outbreak. Nonacute cases experienced the greatest negative effect. The results from this study may inform the orthopaedic surgery community on the effect of future national emergencies, such as viral outbreaks.

Can a Computer-based Force Feedback Hip Fracture Skills Simulator Improve Clinical Task Performance? A Cadaveric Validation Study

BACKGROUND

This cadaveric study seeks to determine whether skills acquired on the simulator translate to improved performance of the clinical task. We hypothesized that completion of simulator training modules would improve performance of percutaneous hip pinning.

METHODS

Eighteen right-handed medical students from two academic institutions were randomized: trained (n = 9) and untrained (n = 9). The trained group completed nine simulator-based modules of increasing difficulty, designed to teach techniques of placing wires in an inverted triangle construct in a valgus-impacted femoral neck fracture. The untrained group had a brief simulator introduction but did not complete the modules. Both groups received a hip fracture lecture, an explanation and pictorial reference of an inverted triangle construct, and instruction on using the wire driver. Participants then placed three 3.2 mm guidewires in cadaveric hips in an inverted triangle construct under fluoroscopy. Wire placement was evaluated with CT at 0.5 mm sections.

RESULTS

The trained group significantly outperformed the untrained group in most parameters (P ≤ 0.05).

CONCLUSIONS

The results suggest that a force feedback simulation platform with simulated fluoroscopic imaging using an established, increasingly difficult series of motor skills training modules has potential to improve clinical performance and might offer an important adjunct to traditional orthopaedic training.

Pediatric Limb Lengthening and Reconstruction Surgical Coding Survey Results

BACKGROUND

In surgical specialties like orthopaedics, documenting the surgery performed involves applying the appropriate current procedural terminology (CPT) code(s). For limb reconstruction surgeons, the wide-ranging types of surgeries and rapid evolution of the field create a variety of factors making it difficult to code the procedures. We sought to (1) assess whether appropriate limb reconstruction codes currently exist and (2) determine whether there is agreement among experienced pediatric orthopaedic surgeons when applying these codes to similar cases.

METHODS

A REDCAP survey comprised of 10 common pediatric limb reconstruction cases was sent to experienced pediatric limb reconstruction surgeons in the United States. Based on the description of each case, the surgeons were asked to code the cases as they usually would in their practice. There were no limitations regarding the number or the types of codes each surgeon could choose to apply to the case. Nine additional demographic and general coding questions were asked to gauge the responding surgeon's coding experience.

RESULTS

Survey participants used various codes for each case, ranging from only 1 code to a maximum of 9 codes to describe a single case. The average number of codes per case ranged from 1.2 to 3.6, with an average of 2.5 among all 10 cases. The total number of unique codes provided by the respondents for each case ranged from 5 to 20. Only 3 of the 10 cases had an agreement >75% for any single code, and only 2 of the 10 cases had >50% agreement on any combination of 2 codes.

CONCLUSIONS

There are dramatic variations in coding methods among pediatric orthopaedic limb reconstruction surgeons. This information highlights the need to improve the current CPT coding landscape. Possible solutions include developing new codes that better represent the work done, developing standardized guidelines with the existing codes to decrease variation, and improving CPT coding education by developing limb reconstruction coding "champions."

LEVEL OF EVIDENCE

Level V.

Case Volume Benchmarks During Residency and Fellowship Training for Pediatric Orthopedic Surgeons

Higher case volumes correlate with improved clinical outcomes across surgical specialties. This study establishes case volume benchmarks after completion of pediatric orthopedic fellowship training. Case logs for orthopedic surgery residents and pediatric orthopedic fellows at accredited programs were analyzed (2017-2018 to 2020-2021). Case volumes for pediatric orthopedic surgery were compared using parametric tests. Case logs from 3,000 orthopedic surgery residents and 149 pediatric orthopedic fellows were analyzed. There was an increase in total pediatric cases among orthopedic surgery residents over the study period (273 ± 68 to 285 ± 76, 1.1% annual increase, P<0.001). On average, pediatric orthopedic fellows reported 276 cases: Spine deformity (55 cases, 20%), foot and ankle deformity (45 cases, 16%), hip reconstruction (34 cases, 12%), limb deformity (32 cases, 12%), trauma lower limb (24 cases, 9%), treatment of supracondylar humerus fracture (23 cases, 8%), trauma upper limb (19 cases, 7%), clubfoot (18 cases, 7%), soft tissue procedures (13 cases, 5%), open treatment of femoral shaft fractures (6 cases, 2%), and treatment of infection (7 cases, 3%). Pediatric orthopedic fellows effectively doubled their pediatric case volume from fellowship training. The distribution of pediatric orthopedic fellow case volume percentiles was: 10^th - 191 cases; 30^th - 237 cases; 50^th - 275 cases; 70^th - 318 cases; 90^th - 382 cases. Case volume benchmarks can help inform orthopedic trainees, faculty, and patients about the impact of pediatric orthopedic fellowship training. More research is needed to elucidate optimal training environments for future pediatric orthopedic surgeons.

Overcoming Systems Factors in Case Logging with Artificial Intelligence Tools

INTRODUCTION

Case logs are foundational data in surgical education, yet cases are consistently under-reported. Logging behavior is driven by multiple human and systems factors, including time constraints, ease of case data retrieval, access to data-entry tools, and procedural code decision tools.

METHODS

We examined case logging trends at three mid-sized, general surgery training programs from September 2016-October 2020, January 2019-October 2020 and May 2019-October 2020, respectively. Across the programs we compared the number of cases logged per week when residents logged directly to ACGME versus via a resident education platform with machine learning-based case logging assistance tools. We examined case logging patterns across 4 consecutive phases: baseline default ACGME logging prior to platform access (P0 "Manual"), full platform logging assistance (P1 "Assisted"), partial platform assistance requiring manual data entry without data integrations (P2 "Notebook"), and resumed fully integrated platform with logging assistance (P3 "Resumed").

RESULTS

31,385 cases were logged utilizing the platform since 2016 by 171 residents across the 3 programs.Intelligent case logging assistance significantly increased case logging rates, from 1.44 ± 1.48 cases by manual entry in P0 to 4.77 ± 2.45 cases per resident per week via the platform in P1 (p-value < 0.00001). Despite the burden of manual data entry when the platform's data connectivity was paused, the tool helped to increase overall case logging into ACGME to 2.85 ± 2.37 cases per week (p-value = 0.0002). Upon resuming the data connectivity, case logging levels rose to 4.54 ± 3.33 cases per week via the platform, equivalent to P1 levels (insignificant difference, p-value = 0.57).

CONCLUSIONS

Mapping the influence of systems and human factors in high-quality case logs allows us to target interventions to continually improve the training of surgical residents. System level factors such as access to alternate automation-drive tools and operative schedule integrated platforms to assist in ACGME case log has a significant impact on the number of cases captured in logs.

Variability in the Duration of Designated Pediatric Orthopaedic Rotations Among US Residency Programs

Our goal was to assess the variability in the assigned duration of pediatric orthopaedic rotation among US allopathic orthopaedic residency programs to see how pediatrics is incorporated into surgical education.

Has the Volume and Variability of Procedures Reported by Fellows in ACGME-accredited Musculoskeletal Oncology Fellowship Programs Changed Over Time?

BACKGROUND

There has been a considerable rise in the number of musculoskeletal/orthopaedic oncology fellowships and subsequently, orthopaedic oncologists, in the nation. National societies have been concerned that the increasing number of orthopaedic oncologists, coupled with a limited number of patients with bone and soft-tissue sarcomas in the country, may have led to an unintended impact on the training spectrum and/or exposure of orthopaedic oncology fellows-in-training over time. Fellows who are unable to gain exposure by operating on varied cancer presentations during training may be less confident in dealing with a wide array of patients in their practice. Despite these concerns, the volume and variability of procedures performed by fellows-in-training remains unknown. Understanding these parameters will be helpful in establishing policies for standardizing training of prospective fellows to ensure they are well-equipped to care for patients with bone and/or soft-tissue sarcomas in the beginning of their career.

QUESTIONS/PURPOSES

(1) Has the median surgical procedure volume per fellow changed over time? (2) How much variability in procedural volume exists between fellows, based on the most recent (2017) Accreditation Council on Graduate Medical Education (ACGME) procedure log data? (3) What proportion of fellows are meeting the minimum procedure volume thresholds, as recommended by the Musculoskeletal Tumor Society (MSTS)?

METHODS

The 2010 to 2017 ACGME fellowship procedure logs for musculoskeletal oncology fellowships were retrieved from the council's official website. All fellows enrolled in ACGME-accredited fellowships are mandated to complete case logs before graduation. This study did not include operative procedures performed by fellows in nonACGME-approved fellowship programs. The 2010 to 2016 anatomic site-based procedure log data were used to evaluate fellows' overall and location-specific median operative or patient volume, using descriptive statistics. Linear regression analyses were used to assess changes in the median procedure volume over time. The 2017 categorized procedure log data were used to assess variability in procedure volume between the lowest (10th percentile) and highest (90th percentile) of all fellows. Using 2017 procedure logs, we compared the minimum procedure volume standards, as defined by the MSTS, against the number of procedures performed by fellows across the 10th, 30th, 50th (median), 70th, and 90th percentiles.

RESULTS

There was no change in the median (range) procedural volume per fellow from 2010 (292 procedures [131 to 634]) to 2017 (312 procedures [174 to 479]; p = 0.58). Based on 2017 categorized procedure log data, there was considerable variability in procedural volume between the lowest (10th) percentile and highest (90th) percentile of fellows across programs: pediatric oncologic procedures (10-fold difference), surgical management of complications from limb-salvage surgery (sevenfold difference), soft-tissue resections or reconstructions (fourfold difference), bone sarcoma resections or limb-salvage surgery (fourfold difference), and spine, sacrum, and pelvis procedures (threefold difference). A fair proportion of fellows did not meet the minimum procedure volume standards, as recommended by the MSTS across certain categories. For the spine and pelvis (minimum = 10 procedures), fellows in the lowest 10th percentile performed only six procedures. For patients with bone sarcomas or limb salvage (minimum = 20 procedures), fellows in the lowest 10th percentile performed only 14 procedures. For pediatric patients with oncologic conditions (minimum = 15 procedures), fellows in the 50th percentile (13 procedures) and below failed to meet the thresholds. For surgical management of complications from limb-salvage procedures (minimum = five procedures), fellows in the lowest 10th percentile performed only three procedures.

CONCLUSION

Although we were encouraged to observe that the median number of procedures performed by musculoskeletal oncology fellows over this time has not changed, we observed wide variability in the procedure volume among fellows for pediatric sarcomas, soft-tissue resection and reconstruction, limb salvage procedures, and spine procedures. We do not know how this compares with fellows trained in nonaccredited fellowship programs.

CLINICAL RELEVANCE

Although we recognize that the education of fellows entails much more than performing operations, national societies have recognized a need to bring about more uniformity or standardization of training in musculoskeletal oncology. Limiting the number of orthopaedic oncology fellowships to high-volume institutions, expanding the training time period, and/or introducing subspecialty certification may be possible avenues through which standardization of training can be defined.

Resident perception of standardization and credentialing for high-risk bedside procedures in cardiothoracic surgery: Results from an institutional pilot study

OBJECTIVES

Though clear-guidelines are set by the American Board of Thoracic Surgery (ABTS) for the operative cases that cardiothoracic surgery residents must perform to be board-eligible, no such recommendations exist to assess competency for the wide range of high-risk bedside procedures. Our department created and implemented a multidisciplinary course designed to standardize common high-risk bedside procedures and credential our trainees. The aim of this study was to survey the attitudes of residents towards and query the efficacy of such a course.

METHODS

The course was designed with the goal of standardizing endotracheal intubation, arterial line insertion (radial and femoral), central venous line insertion, pigtail tube thoracostomy, thoracentesis and nasogastric tube placement. The course consisted of an online module followed by a 4-hour hands-on simulation session. Knowledge-based pre- and post-evaluations were administered as well as a Likert-based survey regarding multiple aspects of the residents' perceptions of the course and the procedures.

RESULTS

Twenty-three (7 traditional and 16 integrated) cardiothoracic surgical residents participated in the course. Residents reported that 48% of the time, bedside procedures were historically taught by other trainees rather than by faculty. All residents endorsed increased standardization of all procedures after the course. Likewise, residents showed increased confidence in all procedures except for pigtail tube thoracostomy, thoracentesis as well as nasogastric tube placement. 43.5% of the participants demonstrated improvement in the pretest and posttest knowledge-based evaluations.

CONCLUSION

Cardiothoracic residents have favorable attitudes towards standardization and credentialing for high-risk bedside procedures and utilizing such courses may help standardize procedural techniques.

The Experiential Benefit of an Orthopedic Trauma Fellowship: An Analysis of ACGME Case Log Data From 2006 to 2017

OBJECTIVE

The Accreditation Council for Graduate Medical Education (ACGME) has published orthopedic case log data since the 2006/2007 academic year. Here, we use this data to analyze the variability in orthopedic trauma case experience reported by orthopedic trainees and to better understand the impact of an orthopedic trauma fellowship on orthopedic surgical training.

DESIGN, SETTING, AND PARTICIPANTS

Data were gathered from ACGME case log reports for orthopedic residents (reporting the cumulative case experience of graduating residents) and orthopedic trauma fellows (reporting the case experience of their fellowship year only) for all available years.

RESULTS

The average orthopedic trauma fellow reported significantly more trauma cases in multiple body regions ("Pelvis/Hip", "Femur/Knee", and "Foot/Toes") and "Open Complex" reductions (as defined by the ACGME) in their 1 year of fellowship than the average resident reported in their 5 years of residency.

CONCLUSION

On average, orthopedic trauma fellowships substantially increase the trauma case volumes of orthopedic trainees, especially with respect to lower extremity trauma.

"What program directors think IV": Results of the 2017 Annual Survey of the Association of Program Directors in Radiology

RATIONALE AND OBJECTIVES

The Association of Program Directors in Radiology (APDR) regularly surveys its members to gather information regarding a broad range of topics related to radiology residency. The survey results provide insight into the opinions of residency program leadership across the country.

MATERIALS AND METHODS

This is an observational cross-sectional study using a web-based survey posed to the APDR membership in the fall of 2017. The final survey consisted of 53 items, 48 multiple choice questions and five write-in comments. An invitation to complete the survey was sent to all 319 active APDR members.

RESULTS

Deidentified responses were collected electronically, tallied utilizing Qualtrics software, and aggregated for the purposes of analysis and reporting at the 66th annual meeting of the Association of University Radiologists. The response rate was 36%.

CONCLUSION

Over the past 16 years, more PDs have assistant and APDs to administer growing residency programs, but the time allocation for these APDs has come from the PD's protected time. An overwhelming majority of PDs consider independent call beneficial to residents and most think a call assistant is desirable. The vast majority of PDs support a unified fellowship match and allow resident moonlighting. Most fourth year residents are actively or moderately involved in clinical work and teaching. The majority of PDs have lost or expect to lose DR training positions to the new IR/DR programs. In a competitive match, PDs do not rely on residency interviews in their selection process.