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Eruchalu CN, Etheridge JC, Hammaker AC, Kader S, Abelson JS, Harvey J, Farr D, Stopenski SJ, Nahmias JT, Elsaadi A, Campbell SJ, Foote DC, Ivascu FA, Montgomery KB, Zmijewski P, Byrd SE, Kimbrough MK, Smith S, Postlewait LM, Dodwad SJM, Adams SD, Markesbery KC, Meister KM, Woeste MR, Martin RCG, Callahan ZM, Marks JA, Patel P, Anstadt MJ, Nasim BW, Willis RE, Patel JA, Newcomb MR, Stahl CC, Yafi MA, Sutton JM, George BC, Quillin RC, Cho NL, Cortez AR. Racial and Ethnic Disparities in Operative Experience Among General Surgery Residents: A Multi-Institutional Study from the US ROPE Consortium. Ann Surg 2024; 279:172-179. [PMID: 36928294 PMCID: PMC11104265 DOI: 10.1097/sla.0000000000005848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Abstract
OBJECTIVE To determine the relationship between race/ethnicity and case volume among graduating surgical residents. BACKGROUND Racial/ethnic minority individuals face barriers to entry and advancement in surgery; however, no large-scale investigations of the operative experience of racial/ethnic minority residents have been performed. METHODS A multi-institutional retrospective analysis of the Accreditation Council for Graduate Medical Education case logs of categorical general surgery residents at 20 programs in the US Resident OPerative Experience Consortium database was performed. All residents graduating between 2010 and 2020 were included. The total, surgeon chief, surgeon junior, and teaching assistant case volumes were compared between racial/ethnic groups. RESULTS The cohort included 1343 residents. There were 211 (15.7%) Asian, 65 (4.8%) Black, 73 (5.4%) Hispanic, 71 (5.3%) "Other" (Native American or Multiple Race), and 923 (68.7%) White residents. On adjusted analysis, Black residents performed 76 fewer total cases (95% CI, -109 to -43, P <0.001) and 69 fewer surgeon junior cases (-98 to -40, P <0.001) than White residents. Comparing adjusted total case volume by graduation year, both Black residents and White residents performed more cases over time; however, there was no difference in the rates of annual increase (10 versus 12 cases per year increase, respectively, P =0.769). Thus, differences in total case volume persisted over the study period. CONCLUSIONS In this multi-institutional study, Black residents graduated with lower case volume than non-minority residents throughout the previous decade. Reduced operative learning opportunities may negatively impact professional advancement. Systemic interventions are needed to promote equitable operative experience and positive culture change.
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Affiliation(s)
- Chukwuma N Eruchalu
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
- Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - James C Etheridge
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- Ariadne Labs, Harvard T.H. Chan School of Public Health, Brigham and Women's Hospital, Boston, MA
| | - Austin C Hammaker
- Department of Surgery, Cincinnati Research on Education in Surgical Training (CREST), University of Cincinnati, Cincinnati, OH
| | - Sarah Kader
- Department of Surgery, Lahey Hospital and Medical Center, Burlington, MA
| | - Jonathan S Abelson
- Department of Surgery, Lahey Hospital and Medical Center, Burlington, MA
| | - Jalen Harvey
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Deborah Farr
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | | | - Jeffry T Nahmias
- Department of Surgery, University of California Irvine, Orange, CA
| | - Ali Elsaadi
- Texas Tech University Health Sciences Center School of Medicine, Lubbock, TX
| | - Samuel J Campbell
- Texas Tech University Health Sciences Center School of Medicine, Lubbock, TX
| | - Darci C Foote
- Department of Surgery, Beaumont Health, Royal Oak, MI
| | | | | | - Polina Zmijewski
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Samuel E Byrd
- Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Mary K Kimbrough
- Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, AR
| | | | | | | | - Sasha D Adams
- Department of Surgery, McGovern Medical School at UTHealth, Houston, TX
| | | | | | | | | | | | - Joshua A Marks
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA
| | - Purvi Patel
- Department of Surgery, Loyola University, Maywood, IL
| | | | - Bilal Waqar Nasim
- Department of Surgery, University of Texas Health Science Center at San Antonio, San Antonio, TX
| | - Ross E Willis
- Department of Surgery, University of Texas Health Science Center at San Antonio, San Antonio, TX
| | - Jitesh A Patel
- Department of Surgery, University of Kentucky, Lexington, KY
| | | | | | - Motaz Al Yafi
- Department of Surgery, University of Toledo, Toledo, OH
| | - Jeffrey M Sutton
- Department of Surgery, Medical University of South Carolina, Division of Oncologic and Endocrine Surgery, Charleston, SC
| | - Brian C George
- Department of Surgery, Center for Surgical Training and Research (CSTAR), University of Michigan, Ann Arbor, MI
| | - Ralph C Quillin
- Department of Surgery, Cincinnati Research on Education in Surgical Training (CREST), University of Cincinnati, Cincinnati, OH
| | - Nancy L Cho
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Alexander R Cortez
- Department of Surgery, Cincinnati Research on Education in Surgical Training (CREST), University of Cincinnati, Cincinnati, OH
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Winer LK, Kader S, Abelson JS, Hammaker AC, Eruchalu CN, Etheridge JC, Cho NL, Foote DC, Ivascu FA, Smith S, Postlewait LM, Greenwell K, Meister KM, Montgomery KB, Zmijewski P, Byrd SE, Kimbrough MK, Stopenski SJ, Nahmias JT, Harvey J, Farr D, Callahan ZM, Marks JA, Stahl CC, Al Yafi M, Sutton JM, Elsaadi A, Campbell SJ, Dodwad SJM, Adams SD, Woeste MR, Martin RC, Patel P, Anstadt MJ, Nasim BW, Willis RE, Patel JA, Newcomb MR, George BC, Quillin RC, Cortez AR. Disparities in the Operative Experience Between Female and Male General Surgery Residents: A Multi-institutional Study From the US ROPE Consortium. Ann Surg 2023; 278:1-7. [PMID: 36994704 PMCID: PMC10896185 DOI: 10.1097/sla.0000000000005847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/31/2023]
Abstract
OBJECTIVE To examine differences in resident operative experience between male and female general surgery residents. BACKGROUND Despite increasing female representation in surgery, sex and gender disparities in residency experience continue to exist. The operative volume of male and female general surgery residents has not been compared on a multi-institutional level. METHODS Demographic characteristics and case logs were obtained for categorical general surgery graduates between 2010 and 2020 from the US Resident OPerative Experience Consortium database. Univariable, multivariable, and linear regression analyses were performed to compare differences in operative experience between male and female residents. RESULTS There were 1343 graduates from 20 Accreditation Council for Graduate Medical Education-accredited programs, and 476 (35%) were females. There were no differences in age, race/ethnicity, or proportion pursuing fellowship between groups. Female graduates were less likely to be high-volume residents (27% vs 36%, P < 0.01). On univariable analysis, female graduates performed fewer total cases than male graduates (1140 vs 1177, P < 0.01), largely due to a diminished surgeon junior experience (829 vs 863, P < 0.01). On adjusted multivariable analysis, female sex was negatively associated with being a high-volume resident (OR = 0.74, 95% CI: 0.56 to 0.98, P = 0.03). Over the 11-year study period, the annual total number of cases increased significantly for both groups, but female graduates (+16 cases/year) outpaced male graduates (+13 cases/year, P = 0.02). CONCLUSIONS Female general surgery graduates performed significantly fewer cases than male graduates. Reassuringly, this gap in operative experience may be narrowing. Further interventions are warranted to promote equitable training opportunities that support and engage female residents.
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Affiliation(s)
- Leah K. Winer
- Department of Surgery, Cincinnati Research on Education in Surgical Training (CREST), University of Cincinnati, Cincinnati, OH
| | - Sarah Kader
- Department of Surgery, Lahey Hospital and Medical Center, Burlington, MA
| | | | - Austin C. Hammaker
- Department of Surgery, Lahey Hospital and Medical Center, Burlington, MA
| | | | | | - Nancy L. Cho
- Department of Surgery, Brigham and Women’s Hospital, Boston, MA
| | - Darci C. Foote
- Department of Surgery, Beaumont Health, Royal Oak, MI
- Department of Surgery, Center for Surgical Training and Research (CSTAR), University of Michigan, Ann Arbor, MI
| | | | | | | | | | | | | | - Polina Zmijewski
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Samuel E. Byrd
- Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Mary K. Kimbrough
- Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, AR
| | | | | | - Jalen Harvey
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas TX
| | - Deborah Farr
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas TX
| | | | - Joshua A. Marks
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA
| | | | - Motaz Al Yafi
- Department of Surgery, University of Toledo, Toledo, OH
| | - Jeffrey M. Sutton
- Division of Oncologic and Endocrine Surgery, Department of Surgery, Medical University of South Carolina, Charleston, SC
| | - Ali Elsaadi
- Texas Tech University Health Sciences Center School of Medicine Lubbock, TX
| | - Samuel J. Campbell
- Texas Tech University Health Sciences Center School of Medicine Lubbock, TX
| | | | - Sasha D. Adams
- Department of Surgery, McGovern Medical School at UTHealth, Houston, TX
| | | | | | - Purvi Patel
- Department of Surgery, Loyola University, Maywood, IL
| | | | - Bilal Waqar Nasim
- Department of Surgery, University of Texas Health Science Center at San Antonio, San Antonio, TX
| | - Ross E. Willis
- Department of Surgery, University of Texas Health Science Center at San Antonio, San Antonio, TX
| | - Jitesh A. Patel
- Department of Surgery, University of Kentucky, Lexington, KY
| | | | - Brian C. George
- Department of Surgery, Center for Surgical Training and Research (CSTAR), University of Michigan, Ann Arbor, MI
| | - Ralph C. Quillin
- Department of Surgery, Cincinnati Research on Education in Surgical Training (CREST), University of Cincinnati, Cincinnati, OH
| | - Alexander R. Cortez
- Department of Surgery, Cincinnati Research on Education in Surgical Training (CREST), University of Cincinnati, Cincinnati, OH
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Hammaker AC, Dodwad SJM, Salyer CE, Adams SD, Foote DC, Ivascu FA, Kader S, Abelson JS, Al Yafi M, Sutton JM, Smith S, Postlewait LM, Stopenski SJ, Nahmias JT, Harvey J, Farr D, Callahan ZM, Marks JA, Elsaadi A, Campbell SJ, Stahl CC, Hanseman DJ, Patel P, Woeste MR, Martin RCG, Patel JA, Newcomb MR, Greenwell K, Meister KM, Etheridge JC, Cho NL, Thrush CR, Kimbrough MK, Nasim BW, Willis RE, George BC, Quillin RC, Cortez AR. A multi-institutional study from the US ROPE Consortium examining factors associated with directly entering practice upon residency graduation. Surgery 2022; 172:906-912. [PMID: 35788283 DOI: 10.1016/j.surg.2022.05.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 05/16/2022] [Accepted: 05/30/2022] [Indexed: 10/17/2022]
Abstract
BACKGROUND There is concern regarding the competency of today's general surgery graduates as a large proportion defer independent practice in favor of additional fellowship training. Little is known about the graduates who directly enter general surgery practice and if their operative experiences during residency differ from graduates who pursue fellowship. METHODS Nineteen Accreditation Council for Graduate Medical Education-accredited general surgery programs from the US Resident OPerative Experience Consortium were included. Demographics, career choice, and case logs from graduates between 2010 to 2020 were analyzed. RESULTS There were 1,264 general surgery residents who graduated over the 11-year period. A total of 248 (19.6%) went directly into practice and 1,016 (80.4%) pursued fellowship. Graduates directly entering practice were more likely to be a high-volume resident (43.1% vs 30.5%, P < .01) and graduate from a high-volume program (49.2% vs 33.0%, P < .01). Direct-to-practice graduates performed 53 more cases compared with fellowship-bound graduates (1,203 vs 1,150, P < .01). On multivariable analysis, entering directly into practice was positively associated with total surgeon chief case volume (odds ratio = 1.47, 95% confidence interval 1.18-1.84, P < .01) and graduating from a US medical school (odds ratio = 2.54, 95% confidence interval 1.45-4.44, P < .01) while negatively associated with completing a dedicated research experience (odds ratio = 0.31, 95% confidence interval 0.22-0.45, P < .01). CONCLUSION This is the first multi-institutional study exploring resident operative experience and career choice. These data suggest residents who desire immediate practice can tailor their experience with less research time and increased operative volume. These data may be helpful for programs when designing their experience for residents with different career goals.
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Affiliation(s)
- Austin C Hammaker
- Department of Surgery, Cincinnati Research on Education in Surgical Training (CREST), University of Cincinnati, Cincinnati, OH. https://twitter.com/HammakerAustin
| | - Shah-Jahan M Dodwad
- Department of Surgery, McGovern Medical School at UTHealth, Houston, TX. https://twitter.com/shahofsurgery
| | - Christen E Salyer
- Department of Surgery, Cincinnati Research on Education in Surgical Training (CREST), University of Cincinnati, Cincinnati, OH. https://twitter.com/salyerchristen
| | - Sasha D Adams
- Department of Surgery, McGovern Medical School at UTHealth, Houston, TX. https://twitter.com/SashaTrauma
| | - Darci C Foote
- Department of Surgery, Beaumont Health, Royal Oak, MI
| | | | - Sarah Kader
- Department of Surgery, Lahey Hospital and Medical Center, Burlington, MA
| | - Jonathan S Abelson
- Department of Surgery, Lahey Hospital and Medical Center, Burlington, MA. https://twitter.com/jabelsonmd
| | - Motaz Al Yafi
- Department of Surgery, University of Toledo, Toledo, OH
| | - Jeffrey M Sutton
- Department of Surgery, Division of Surgical Oncology, Medical University of South Carolina, Charleston, SC. https://twitter.com/J_M_Sutton
| | | | | | | | - Jeffry T Nahmias
- Department of Surgery, University of California, Irvine, Orange, CA. https://twitter.com/jnahmias1
| | - Jalen Harvey
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas TX. https://twitter.com/JHarvMD20
| | - Deborah Farr
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas TX. https://twitter.com/DVFelaine
| | - Zachary M Callahan
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA. https://twitter.com/zmcallahan
| | - Joshua A Marks
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA
| | - Ali Elsaadi
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, TX
| | - Samuel J Campbell
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, TX
| | | | - Dennis J Hanseman
- Department of Surgery, Cincinnati Research on Education in Surgical Training (CREST), University of Cincinnati, Cincinnati, OH
| | - Purvi Patel
- Department of Surgery, Loyola University, Maywood, IL. https://twitter.com/pppatelmd
| | | | | | - Jitesh A Patel
- Department of Surgery, University of Kentucky, Lexington, KY. https://twitter.com/Patel_Wildcat
| | | | | | | | | | - Nancy L Cho
- Department of Surgery, Brigham and Women's Hospital, Boston, MA. https://twitter.com/NancyLCho
| | - Carol R Thrush
- Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Mary K Kimbrough
- Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, AR. https://twitter.com/kimbrough_katie
| | - Bilal Waqar Nasim
- Department of Surgery, University of Texas Health Science Center at San Antonio, San Antonio, TX
| | - Ross E Willis
- Department of Surgery, University of Texas Health Science Center at San Antonio, San Antonio, TX
| | - Brian C George
- Department of Surgery, Center for Surgical Training and Research (CSTAR), University of Michigan, Ann Arbor, MI. https://twitter.com/bcgeorge
| | - Ralph C Quillin
- Department of Surgery, Cincinnati Research on Education in Surgical Training (CREST), University of Cincinnati, Cincinnati, OH
| | - Alexander R Cortez
- Department of Surgery, Cincinnati Research on Education in Surgical Training (CREST), University of Cincinnati, Cincinnati, OH.
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Schwartz PB, Stahl CC, Vidri RJ, Leverson GE, Puckett Y, Zafar SN, Varley P, Ronnekleiv-Kelly SM, Al-Niaimi A, Weber SM, Abbott DE. ASO Visual Abstract: Rethinking Routine Intensive Care After Cytoreductive Surgery with Heated Intraperitoneal Chemotherapy: The Fiscal Argument. Ann Surg Oncol 2022. [DOI: 10.1245/s10434-022-12017-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Schwartz PB, Stahl CC, Vidri RJ, Leverson GE, Puckett Y, Zafar SN, Varley P, Ronnekleiv-Kelly SM, Al-Niaimi A, Weber SM, Abbott DE. Rethinking Routine Intensive Care After Cytoreductive Surgery With Heated Intraperitoneal Chemotherapy: The Fiscal Argument. Ann Surg Oncol 2022; 29:6606-6614. [PMID: 35672624 DOI: 10.1245/s10434-022-11967-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 05/20/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Patients undergoing cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) are frequently admitted to the intensive care unit (ICU) for mitigation of potential complications, although ICU length of stay (LOS) is a significant driver of cost. This study asked whether a fiscal argument could be made for the selective avoidance of ICU admission after CRS/HIPEC. METHODS Prospective data for select low-risk patients (e.g., lower peritoneal cancer index [PCI]) admitted to the intermediate care unit (IMC) instead of the ICU after CRS/HIPEC were matched with a historic cohort routinely admitted to the ICU. Cohort comparisons and the impact of the intervention on cost were assessed. RESULTS The study matched 81 CRS/HIPEC procedures to form a cohort of 49 pre- and 15 post-intervention procedures for patients with similar disease burdens (mean PCI, 8 ± 6.7 vs. 7 ± 5.1). The pre-intervention patients stayed a median of 1 day longer in the ICU (1 day [IQR, 1-1 day] vs. 0 days [IQR, 0-0 days]) and had a longer LOS (8 days [IQR, 7-11 days] vs. 6 days [IQR, 5.5-9 days]). Complications and complication severity did not differ statistically. The median total hospital cost was lower after intervention ($30,845 [IQR, $30,181-$37,725] vs. $41,477 [IQR, $33,303-$51,838]), driven by decreased indirect fixed cost ($8984 [IQR, $8643-$11,286] vs. $14,314 [IQR, $12,206-$18,266]). In a weighted multiple variable linear regression analysis, the intervention was associated with a savings of $2208.68 per patient. CONCLUSIONS Selective admission to the IMC after CRS/HIPEC was associated with $2208.68 in savings per patient without added risk. In this era of cost-conscious practice of medicine, these data highlight an opportunity to decrease cost by more than 5% for patients undergoing CRS/HIPEC.
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Affiliation(s)
- Patrick B Schwartz
- Department of Surgery, Division of Surgical Oncology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA.
| | - Christopher C Stahl
- Department of Surgery, Division of Surgical Oncology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Roberto J Vidri
- Department of Surgery, Division of Surgical Oncology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Glen E Leverson
- Department of Surgery, Division of Surgical Oncology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Yana Puckett
- Department of Surgery, Division of Surgical Oncology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Syed N Zafar
- Department of Surgery, Division of Surgical Oncology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Patrick Varley
- Department of Surgery, Division of Surgical Oncology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Sean M Ronnekleiv-Kelly
- Department of Surgery, Division of Surgical Oncology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Ahmed Al-Niaimi
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Sharon M Weber
- Department of Surgery, Division of Surgical Oncology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Daniel E Abbott
- Department of Surgery, Division of Surgical Oncology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
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Padilla EP, Stahl CC, Jung SA, Rosser AA, Schwartz PB, Aiken T, Acher AW, Abbott DE, Greenberg JA, Minter RM. Gender Differences in Entrustable Professional Activity Evaluations of General Surgery Residents. Ann Surg 2022; 275:222-229. [PMID: 33856381 PMCID: PMC8514571 DOI: 10.1097/sla.0000000000004905] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To determine differences in entrustable professional activity (EPA) assessments between male and female general surgery residents. SUMMARY BACKGROUND DATA Evaluations play a critical role in career advancement for physicians. However, female physicians in training receive lower evaluations and underrate their own performance. Competency-based assessment frameworks, such as EPAs, may help address gender bias in surgery by linking evaluations to specific, observable behaviors. METHODS In this cohort study, EPA assessments were collected from July 2018 to May 2020. The effect of resident sex on EPA entrustment levels was analyzed using multiple linear and ordered logistic regressions. Narrative comments were analyzed using latent dirichlet allocation to identify topics correlated with resident sex. RESULTS Of the 2480 EPAs, 1230 EPAs were submitted by faculty and 1250 were submitted by residents. After controlling for confounding factors, faculty evaluations of residents were not impacted by resident sex (estimate = 0.09, P = 0.08). However, female residents rated themselves lower by 0.29 (on a 0-4 scale) compared to their male counterparts (P < 0.001). Within narrative assessments, topics associated with resident sex demonstrated that female residents focus on the "guidance" and "supervision" they received while performing an EPA, while male residents were more likely to report "independent" action. CONCLUSIONS Faculty assessments showed no difference in EPA levels between male and female residents. Female residents rate themselves lower by nearly an entire post graduate year (PGY) level compared to male residents. Latent dirichlet allocation -identified topics suggest this difference in self-assessment is related to differences in perception of autonomy.
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Affiliation(s)
- Elena P. Padilla
- University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Christopher C. Stahl
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Sarah A. Jung
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Alexandra A. Rosser
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Patrick B. Schwartz
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Taylor Aiken
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Alexandra W. Acher
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Daniel E. Abbott
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Jacob A. Greenberg
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Rebecca M. Minter
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
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Aiken TJ, Stahl CC, Lemaster D, Casias TW, Walker BJ, Nichol PF, Leys CM, Abbott DE, Brinkman AS. Intercostal nerve cryoablation is associated with lower hospital cost during minimally invasive Nuss procedure for pectus excavatum. J Pediatr Surg 2021; 56:1841-1845. [PMID: 33199059 PMCID: PMC8053720 DOI: 10.1016/j.jpedsurg.2020.10.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 09/30/2020] [Accepted: 10/09/2020] [Indexed: 01/12/2023]
Abstract
UNLABELLED Minimally invasive repair of pectus excavatum (Nuss procedure) is associated with significant pain, and efforts to control pain impact resource utilization. Bilateral thoracic intercostal nerve cryoablation has been proposed as a novel technique to improve post-operative pain control, though the impact on hospital cost is unknown. METHODS We conducted a retrospective study of patients undergoing a Nuss procedure from 2016 to 2019. Patients who received cryoablation were compared to those that received traditional pain control (patient-controlled analgesia or epidural). Outcome variables included postoperative opioid usage (milligram morphine equivalents, MME), length of stay (LOS), and hospital cost. RESULTS Thirty-five of 73 patients studied (48%) received intercostal nerve cryoablation. LOS (1.0 vs 4.0 days, p < 0.01) and total hospital cost ($21,924 versus $23,694, p = 0.04) were decreased in the cryoablation cohort, despite longer operative time (152 vs 74 min, p < 0.01). Cryoablation was associated with decreased opioid usage (15.0 versus 148.6 MME, p < 0.01) during the 24 h following surgery and this persisted over the entire postoperative period, including discharge opioid prescription (112.5 vs 300.0 MME, p < 0.01). CONCLUSION Bilateral intercostal nerve cryoablation is associated with decreased postoperative opioid usage and decreased resource utilization in pediatric patients undergoing a minimally invasive Nuss procedure for pectus excavatum. LEVEL OF EVIDENCE Retrospective comparative study, level III.
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Affiliation(s)
- Taylor J. Aiken
- Department of Surgery, University of Wisconsin Hospitals and Clinics, 600 Highland Ave, Madison, WI USA 53792
| | - Christopher C. Stahl
- Department of Surgery, University of Wisconsin Hospitals and Clinics, 600 Highland Ave, Madison, WI USA 53792
| | - Deborah Lemaster
- Department of Surgery, University of Wisconsin Hospitals and Clinics, 600 Highland Ave, Madison, WI USA 53792
| | - Timothy W. Casias
- Division of Pediatric Anesthesiology, Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, 600 Highland Avenue, Madison, WI USA 53792
| | - Benjamin J. Walker
- Division of Pediatric Anesthesiology, Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, 600 Highland Avenue, Madison, WI USA 53792
| | - Peter F. Nichol
- Division of Pediatric Surgery, Department of Surgery, University of Wisconsin Hospitals and Clinics, 600 Highland Ave, Madison, WI USA 53792
| | - Charles M. Leys
- Division of Pediatric Surgery, Department of Surgery, University of Wisconsin Hospitals and Clinics, 600 Highland Ave, Madison, WI USA 53792
| | - Daniel E. Abbott
- Department of Surgery, University of Wisconsin Hospitals and Clinics, 600 Highland Ave, Madison, WI USA 53792
| | - Adam S. Brinkman
- Division of Pediatric Surgery, Department of Surgery, University of Wisconsin Hospitals and Clinics, 600 Highland Ave, Madison, WI USA 53792
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8
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Stahl CC, Abbott DE. ASO Author Reflections: Kidney Function After Retroperitoneal Sarcoma Resection with Nephrectomy. Ann Surg Oncol 2021; 28:1697-1698. [PMID: 33146840 PMCID: PMC7897261 DOI: 10.1245/s10434-020-09292-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 08/26/2020] [Indexed: 11/18/2022]
Affiliation(s)
| | - Daniel E Abbott
- Department of Surgery, University of Wisconsin, Madison, WI, USA
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Stahl CC, Funk LM, Schumacher JR, Zarzaur BL, Scarborough JE. The Relative Impact of Specific Postoperative Complications on Older Patients Undergoing Hip Fracture Repair. Jt Comm J Qual Patient Saf 2020; 47:210-216. [PMID: 33451895 DOI: 10.1016/j.jcjq.2020.12.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 11/16/2020] [Accepted: 12/10/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Hip fractures affect a vulnerable population and are associated with high rates of morbidity, mortality, and resource utilization. Although postoperative complications are a known driver of mortality and resource utilization, the comparative impacts of specific complications on outcomes is unknown. This study assessed which complications are associated with the highest effects on mortality and resource utilization for older patients who undergo hip fracture repair. METHODS Patients ≥ 65 years of age who underwent hip fracture repair during 2016-2017 included in the Hip Fracture Targeted ACS NSQIP (American College of Surgeons National Surgical Quality Improvement Program) database populated the data set. Prolonged hospitalization (≥ 75th percentile) and 30-day mortality and readmission were the primary outcomes. Population attributable fractions (PAFs) were used to quantify the anticipated reduction in the primary outcomes that would result from complete prevention of 10 postoperative complications. RESULTS Of 17,755 patients across 117 hospitals, 70.9% were female, 26.0% were over age 90, 22.8% had an American Society of Anesthesiologists (ASA) score of 4-5, and 53.9% presented with an intertrochanteric fracture. Postoperative delirium affected 29.8% of patients and was associated with death (PAF 18.0%; 95% confidence interval [CI] = 13.2-22.5), prolonged hospitalization (PAF 14.3%; 95% CI = 12.7-15.8), and readmission (PAF 15.0%; 95% CI = 11.3-18.6). Pneumonia affected 4.1% of patients and was associated with death (PAF 10.9%; 95% CI = 8.9-12.8), prolonged hospitalization (PAF 4.0%; 95% CI = 3.5-4.5), and readmission (PAF 9.1%; 95% CI = 7.5-10.7). The impact of the other eight complications was comparatively small. CONCLUSION Postoperative delirium and pneumonia are the highest-impact complications for older hip fracture repair patients. These complications should be prioritized in quality improvement efforts that target this patient population.
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Stahl CC, Jung SA, Rosser AA, Kraut AS, Schnapp BH, Westergaard M, Hamedani AG, Minter RM, Greenberg JA. Natural language processing and entrustable professional activity text feedback in surgery: A machine learning model of resident autonomy. Am J Surg 2020; 221:369-375. [PMID: 33256944 DOI: 10.1016/j.amjsurg.2020.11.044] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 11/19/2020] [Accepted: 11/21/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Entrustable Professional Activities (EPAs) contain narrative 'entrustment roadmaps' designed to describe specific behaviors associated with different entrustment levels. However, these roadmaps were created using expert committee consensus, with little data available for guidance. Analysis of actual EPA assessment narrative comments using natural language processing may enhance our understanding of resident entrustment in actual practice. METHODS All text comments associated with EPA microassessments at a single institution were combined. EPA-entrustment level pairs (e.g. Gallbladder Disease-Level 1) were identified as documents. Latent Dirichlet Allocation (LDA), a common machine learning algorithm, was used to identify latent topics in the documents associated with a single EPA. These topics were then reviewed for interpretability by human raters. RESULTS Over 18 months, 1015 faculty EPA microassessments were collected from 64 faculty for 80 residents. LDA analysis identified topics that mapped 1:1 to EPA entrustment levels (Gammas >0.99). These LDA topics appeared to trend coherently with entrustment levels (words demonstrating high entrustment were consistently found in high entrustment topics, word demonstrating low entrustment were found in low entrustment topics). CONCLUSIONS LDA is capable of identifying topics relevant to progressive surgical entrustment and autonomy in EPA comments. These topics provide insight into key behaviors that drive different level of resident autonomy and may allow for data-driven revision of EPA entrustment maps.
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Affiliation(s)
- Christopher C Stahl
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Sarah A Jung
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Alexandra A Rosser
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Aaron S Kraut
- Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Benjamin H Schnapp
- Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Mary Westergaard
- Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Azita G Hamedani
- Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Rebecca M Minter
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Jacob A Greenberg
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.
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11
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Stahl CC, Schwartz PB, Ethun CG, Marka N, Krasnick BA, Tran TB, Poultsides GA, Roggin KK, Fields RC, Clarke CN, Votanopoulos KI, Cardona K, Abbott DE. Renal Function After Retroperitoneal Sarcoma Resection with Nephrectomy: A Matched Analysis of the United States Sarcoma Collaborative Database. Ann Surg Oncol 2020; 28:1690-1696. [PMID: 33146839 DOI: 10.1245/s10434-020-09290-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 08/14/2020] [Indexed: 01/19/2023]
Abstract
BACKGROUND Nephrectomy often is required during en bloc resection of a retroperitoneal sarcoma (RPS) to achieve an R0 or R1 resection. The impact of nephrectomy on postoperative renal function in this patient population, who also may benefit from subsequent nephrotoxic systemic therapy, is not well described. METHODS The United States Sarcoma Collaborative (USSC) database was queried for patients undergoing RPS resection between 2000 and 2016. Patients with missing pre- or postoperative measures of renal function were excluded. A matched cohort was created using coarsened exact matching. Weighted logistic regression was used to control further for differences between the nephrectomy and non-nephrectomy cohorts. The primary outcomes were postoperative acute kidney injury (AKI), acute renal failure (ARF), and dialysis. RESULTS The initial cohort consisted of 858 patients, 3 (0.3%) of whom required postoperative dialysis. The matched cohort consisted of 411 patients, 108 (26%) of whom underwent nephrectomy. The patients who underwent nephrectomy had higher rates of postoperative AKI (14.8% vs 4.3%; p < 0.01) and ARF (4.6% vs 1.3%; p = 0.04), but no patients required dialysis postoperatively. Logistic regression modeling showed that the risk of AKI (odds ratio [OR], 5.16; p < 0.01) and ARF (OR 5.04; p < 0.01) after nephrectomy persisted despite controlling for age and preoperative renal function. CONCLUSIONS Nephrectomy is associated with an increased risk of postoperative AKI and ARF after RPS resection. This study was unable to statistically assess the impact of nephrectomy on postoperative dialysis, but the risk of postoperative dialysis is 0.5% or less regardless of nephrectomy status.
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Affiliation(s)
| | | | - Cecilia G Ethun
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Nicholas Marka
- Department of Surgery, University of Wisconsin, Madison, WI, USA
| | | | | | | | | | - Ryan C Fields
- Siteman Cancer Center, Washington University, St. Louis, MO, USA
| | | | | | - Kenneth Cardona
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Daniel E Abbott
- Department of Surgery, University of Wisconsin, Madison, WI, USA
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12
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Stahl CC, Jung SA, Rosser AA, Kraut AS, Schnapp BH, Westergaard M, Hamedani AG, Minter RM, Greenberg JA. Entrustable Professional Activities in General Surgery: Trends in Resident Self-Assessment. J Surg Educ 2020; 77:1562-1567. [PMID: 32540120 DOI: 10.1016/j.jsurg.2020.05.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 05/05/2020] [Accepted: 05/05/2020] [Indexed: 05/23/2023]
Abstract
OBJECTIVE Effective self-assessment is a cornerstone of lifelong professional development; however, evidence suggests physicians have a limited ability to self-assess. Novel strategies to improve the accuracy of learner self-assessment are needed. Our institution's surgical entrustable professional activity (EPA) implementation strategy incorporates resident self-assessment to address this issue. This study evaluates the accuracy of resident self-assessment versus faculty assessment across 5 EPAs in general surgery. DESIGN, SETTING, PARTICIPANTS Within a single academic general surgery residency program, assessment data for 5 surgery EPAs was prospectively collected using a mobile application. Matched assessments (resident and faculty assessments for the same clinical encounter) were identified and the remainder excluded. Assessment scores were compared using Welch's t test. Agreement was analyzed using Cohen's kappa with squared weights. RESULTS One thousand eight hundred and fifty-seven EPA assessments were collected in 17 months following implementation. One thousand one hundred and fifty-five (62.2%) were matched pairs. Residents under-rated their own performance relative to faculty assessments (2.36 vs 2.65, p < 0.01). This pattern held true for all subsets except for Postgraduate Year (PGY)2 residents and Inguinal Hernia EPAs. There was at least moderate agreement between matched resident and faculty EPA assessment scores (κ = 0.57). This was consistent for all EPAs except Trauma evaluations, which were completed by faculty from 2 different departments. Surgery resident self-assessments more strongly agreed with Surgery faculty assessments than Emergency Medicine faculty assessments (κ = 0.58 vs 0.36). CONCLUSIONS Resident EPA self-assessments are equivalent or slightly lower than faculty assessments across a wide breadth of clinical scenarios. Resident and faculty matched assessments demonstrate moderate agreement.
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Affiliation(s)
- Christopher C Stahl
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Sarah A Jung
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Alexandra A Rosser
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Aaron S Kraut
- Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Benjamin H Schnapp
- Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Mary Westergaard
- Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Azita G Hamedani
- Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Rebecca M Minter
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Jacob A Greenberg
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin.
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13
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Isom CA, Bisgaard EK, Campbell KM, Courtney C, Erickson C, Faber DA, Gauger PG, Greenberg JA, Kassam AF, Mullen JT, Phares A, Quillin RC, Salcedo ES, Schaffer AJ, Scaria D, Stahl CC, Wise PE, Kauffmann RM, Chen X, Smith JJ, Terhune KP. Does Intentional Support of Degree Programs in General Surgery Residency Affect Research Productivity or Pursuit of Academic Surgery? A Multi-Institutional Study. J Surg Educ 2020; 77:e34-e38. [PMID: 32843316 DOI: 10.1016/j.jsurg.2020.07.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Revised: 07/13/2020] [Accepted: 07/13/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVE To determine whether pursuit of an advanced degree during dedicated research time (DRT) in a general surgery residency training program impacts a resident's research productivity. DESIGN A retrospective, multi-institutional cohort study. SETTING General surgery residency programs that were approved to graduate more than 5 categorical residents per year and that offered at least 1 year of DRT were contacted for participation in the study. A total of 10 general surgery residency programs agreed to participate in the study. PARTICIPANTS Residents who started their residency between 2000 and 2012 and spent at least one full year in DRT (n = 511) were included. Those who completed an advanced degree were compared on the following parameters to those who did not complete one: total number of papers, first-author papers, the Journal Citation Reports impact factors of publication (2018, or most recent), and first position after residency or fellowship training. RESULTS During DRT, 87 (17%) residents obtained an advanced degree. The most common degree obtained was a Master of Public Health (MPH, n = 42 (48.8%)). Residents who did not obtain an advanced degree during DRT published fewer papers (median 8, [interquartile range 4-12]) than those who obtained a degree (9, [6-17]) (p = 0.002). They also published fewer first author papers (3, [2-6]) vs (5, [2-9]) (p = 0.002) than those who obtained a degree. Resident impact factor (RIF) was calculated using Journal Citation Reports impact factor and author position. Those who did not earn an advanced degree had a lower RIF (adjusted RIF, 84 ± 4 vs 134 ± 5, p < 0.001) compared to those who did. There was no association between obtaining a degree and pursuit of academic surgery (p = 0.13) CONCLUSIONS: Pursuit of an advanced degree during DRT is associated with increased research productivity but is not associated with pursuit of an academic career.
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Affiliation(s)
- Chelsea A Isom
- Vanderbilt University Medical Center, Nashville, Tennessee
| | | | | | | | | | - David A Faber
- Emory University School of Medicine, Department of Surgery
| | | | | | | | | | | | | | | | | | - Denny Scaria
- Baylor College of Medicine, Department of General Surgery
| | | | - Paul E Wise
- Emory University School of Medicine, Department of Surgery
| | | | - Xi Chen
- Department of Public Health Sciences, University of Miami Miller School or Medicine; Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine
| | - J Joshua Smith
- Memorial Sloan Kettering Cancer Center, Department of Surgery
| | - Kyla P Terhune
- Vanderbilt University Medical Center, Nashville, Tennessee.
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Stahl CC, Aiken T, Lemaster D, Nichol PF, Leys CM, Abbott DE, Brinkman AS. Intercostal Nerve Cryoablation Decreases Opioid Usage and Hospital Cost in Patients Undergoing Nuss Procedure. J Am Coll Surg 2020. [DOI: 10.1016/j.jamcollsurg.2020.07.571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Zarzaur BL, Stahl CC, Greenberg JA, Savage SA, Minter RM. Blueprint for Restructuring a Department of Surgery in Concert With the Health Care System During a Pandemic: The University of Wisconsin Experience. JAMA Surg 2020; 155:628-635. [PMID: 32286611 DOI: 10.1001/jamasurg.2020.1386] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The current health care environment is complex. Systems often cross US state boundaries to provide care to patients with a wide variety of medical needs. The coronavirus disease 2019 pandemic is challenging health care systems across the globe. Systems face varying levels of complexity as they adapt to the new reality. This pandemic continues to escalate in hot spots nationally and internationally, and the worst strain on health care systems may be yet to come. The purpose of this article is to provide a road map developed from lessons learned from the experience in the Department of Surgery at the University of Wisconsin School of Medicine and Public Health and University of Wisconsin Health, based on past experience with incident command structures in military combat operations and Federal Emergency Management Agency responses. We will discuss administrative restructuring leveraging a team-of-teams approach, provide a framework for deploying the workforce needed to deliver all necessary urgent health care and critical care to patients in the system, and consider implications for the future.
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Affiliation(s)
- Ben L Zarzaur
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison
| | - Christopher C Stahl
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison
| | - Jacob A Greenberg
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison
| | - Stephanie A Savage
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison
| | - Rebecca M Minter
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison
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Aiken TJ, Stahl CC, Schwartz PB, Barrett J, Acher AW, Lemaster D, Leverson G, Weber S, Neuman H, Abbott DE. Sentinel lymph node biopsy is associated with increased cost in higher risk thin melanoma. J Surg Oncol 2020; 123:104-109. [PMID: 32939750 DOI: 10.1002/jso.26225] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 08/25/2020] [Accepted: 09/08/2020] [Indexed: 02/02/2023]
Abstract
INTRODUCTION National Comprehensive Cancer Network guidelines recommend that sentinel lymph node biopsy (SLNB) be discussed with patients with thin melanoma at higher risk for lymph node metastasis (T1b or T1a with positive deep margins, lymphovascular invasion, or high mitotic index). We examined the association between SLNB and resource utilization in this cohort. METHODS We conducted a retrospective cohort study of patients that underwent wide local excision for higher risk thin melanomas from 2009 to 2018 at a tertiary care center. Patients who underwent SLNB were compared to those who did not undergo SLNB with regard to resource utilization, including total hospital cost. RESULTS A total of 70 patients were included in the analysis and 50 patients (71.4%) underwent SLNB. SLNB was associated with increased hospital costs ($6700 vs. $3767; p < .01) and increased operative time (68.5 vs. 36.0 min; p < .01). This cost difference persisted in multivariable regression (p < .01). Of patients who underwent successful SLN mapping, 3 out of 49 patients had a positive SLN (6.1%). The cost to identify a single positive sentinel lymph node (SLN) was $47,906. CONCLUSION In patients with a higher risk of thin melanoma, SLNB is associated with increased cost despite a low likelihood of SLN positivity. These data better inform patient-provider discussions as the role of SLNB in thin melanoma evolves.
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Affiliation(s)
- Taylor J Aiken
- Department of Surgery, University of Wisconsin Hospitals and Clinics, Madison, Wisconsin, USA
| | - Christopher C Stahl
- Department of Surgery, University of Wisconsin Hospitals and Clinics, Madison, Wisconsin, USA
| | - Patrick B Schwartz
- Department of Surgery, University of Wisconsin Hospitals and Clinics, Madison, Wisconsin, USA
| | - James Barrett
- Department of Surgery, University of Wisconsin Hospitals and Clinics, Madison, Wisconsin, USA
| | - Alexandra W Acher
- Department of Surgery, University of Wisconsin Hospitals and Clinics, Madison, Wisconsin, USA
| | - Deborah Lemaster
- Department of Surgery, University of Wisconsin Hospitals and Clinics, Madison, Wisconsin, USA
| | - Glen Leverson
- Department of Surgery, University of Wisconsin Hospitals and Clinics, Madison, Wisconsin, USA
| | - Sharon Weber
- Department of Surgery, University of Wisconsin Hospitals and Clinics, Madison, Wisconsin, USA
| | - Heather Neuman
- Department of Surgery, University of Wisconsin Hospitals and Clinics, Madison, Wisconsin, USA
| | - Daniel E Abbott
- Department of Surgery, University of Wisconsin Hospitals and Clinics, Madison, Wisconsin, USA
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17
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Schwartz PB, Stahl CC, Ethun C, Marka N, Poultsides GA, Roggin KK, Fields RC, Howard JH, Clarke CN, Votanopoulos KI, Cardona K, Abbott DE. Retroperitoneal sarcoma perioperative risk stratification: A United States Sarcoma Collaborative evaluation of the ACS-NSQIP risk calculator. J Surg Oncol 2020; 122:795-802. [PMID: 32557654 PMCID: PMC7744355 DOI: 10.1002/jso.26071] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Accepted: 06/06/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND The ACS-NSQIP risk calculator predicts perioperative risk. This study tested the calculator's ability to predict risk for outcomes following retroperitoneal sarcoma (RPS) resection. METHODS The United States Sarcoma Collaborative database was queried for adults who underwent RPS resection. Estimated risk for outcomes was calculated twice in the risk calculator, once using sarcoma-specific CPT codes and once using codes indicative of most comorbid organ resection (eg nephrectomy). ROC curves were generated, with area under the curve (AUC) and Brier scores reported to assess discrimination and calibration. An AUC < 0.6 was considered ineffective discrimination. A negative ▲ Brier indicated improved performance relative to baseline outcome rates. RESULTS In total, 482 patients were identified with a 42.3% 90-day complication rate. Discrimination was poor for all outcomes except "all complications" and "renal failure." Baseline outcome rates were better predictors than calculator estimates except for "discharge to nursing or rehab facility" and "renal failure." Replacing sarcoma-specific CPT codes with resection-specific codes did not improve performance. CONCLUSION The ACS-NSQIP risk calculator poorly predicted outcomes following RPS resection. Changing sarcoma-specific CPT to resection-specific codes did not improve performance. Comorbidities in the calculator may not effectively capture perioperative risk. Future work should evaluate a sarcoma-specific calculator.
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Affiliation(s)
- Patrick B Schwartz
- Department of Surgery, Division of Surgical Oncology, University of Wisconsin, Madison, Wisconsin
| | - Christopher C Stahl
- Department of Surgery, Division of Surgical Oncology, University of Wisconsin, Madison, Wisconsin
| | - Cecilia Ethun
- Department of Surgery, Division of Surgical Oncology, Emory University, Atlanta, Georgia
| | - Nicholas Marka
- Department of Surgery, Division of Surgical Oncology, University of Wisconsin, Madison, Wisconsin
| | - George A Poultsides
- Department of Surgery, Division of Surgical Oncology, Stanford University, Palo Alto, California
| | - Kevin K Roggin
- Department of Surgery, University of Chicago Medicine, Chicago, Illinois
| | - Ryan C Fields
- Department of Surgery, Siteman Cancer Center, Washington University, St. Louis, Missouri
| | - John H Howard
- Department of Surgery, Division of Surgical Oncology, The Ohio State University, Columbus, Ohio
| | - Callisia N Clarke
- Department of Surgery, Division of Surgical Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | | | - Kenneth Cardona
- Department of Surgery, Division of Surgical Oncology, Emory University, Atlanta, Georgia
| | - Daniel E Abbott
- Department of Surgery, Division of Surgical Oncology, University of Wisconsin, Madison, Wisconsin
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Affiliation(s)
- Christopher C Stahl
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, H4/710D Clinical Science Center, 600 Highland Avenue, Madison, WI 53792-7375, USA
| | - Rebecca M Minter
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, H4/710D Clinical Science Center, 600 Highland Avenue, Madison, WI 53792-7375, USA.
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19
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Stahl CC, Collins E, Jung SA, Rosser AA, Kraut AS, Schnapp BH, Westergaard M, Hamedani AG, Minter RM, Greenberg JA. Implementation of Entrustable Professional Activities into a General Surgery Residency. J Surg Educ 2020; 77:739-748. [PMID: 32044326 PMCID: PMC7305986 DOI: 10.1016/j.jsurg.2020.01.012] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 01/15/2020] [Accepted: 01/21/2020] [Indexed: 06/01/2023]
Abstract
OBJECTIVE Concerns over resident ability to practice effectively after graduation have led to the competency-based medical education movement. Entrustable professional activities (EPAs) may facilitate competency-based medical education in surgery, but implementation is challenging. This manuscript describes 1 strategy used to implement EPAs into an academic general surgery residency. DESIGN, SETTING, PARTICIPANTS A mobile application was developed incorporating 5 EPAs developed by the American Board of Surgery; residents and faculty from the Departments of Surgery, Emergency Medicine, and Hospital Medicine at a single tertiary care center were trained in its use. Entrustment levels and free text feedback were collected. Self-assessment was paired with supervisor assessment, and faculty assessments were used to inform clinical competency committee entrustment decisions. Feedback was regularly solicited from app users and results distributed on a monthly basis. RESULTS One thousand seven hundred and twenty microassessments were collected over the first 16 months of implementation; 898 (47.8%) were performed by faculty with 569 (66.0%) matched pairs. Engagement was skewed with small numbers of high performers in both resident and faculty groups. Continued development of resident and faculty was required to sustain engagement with the program. Nonsurgical specialties contributed significantly to resident assessments (496, 28.8%). CONCLUSIONS EPAs are being successfully integrated into the assessment framework at our institution. EPA implementation in surgery residency is a long-term process that requires investment, but may address limitations in the current assessment framework.
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Affiliation(s)
- Christopher C Stahl
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Eric Collins
- Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Sarah A Jung
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Alexandra A Rosser
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Aaron S Kraut
- Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Benjamin H Schnapp
- Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Mary Westergaard
- Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Azita G Hamedani
- Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Rebecca M Minter
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Jacob A Greenberg
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin.
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20
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Schwartz PB, Stahl CC, Vande Walle KA, Pokrzywa CJ, Cherney Stafford LM, Aiken T, Barrett J, Acher AW, Leverson G, Ronnekleiv-Kelly S, Weber SM, Abbott DE. What Drives High Costs of Cytoreductive Surgery and HIPEC: Patient, Provider or Tumor? Ann Surg Oncol 2020; 27:4920-4928. [PMID: 32415351 DOI: 10.1245/s10434-020-08583-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) is utilized for peritoneal malignancies and is associated with significant resource use. To address potentially modifiable factors contributing to excessive cost, we sought to determine predictors of high cost of care for patients undergoing CRS/HIPEC. METHODS An institutional CRS/HIPEC database was queried for adult patients from 2014 to 2018. Cost was defined as cost for the index hospitalization, and high-cost cases were defined as > 75th percentile for cost. Bivariate analyses for cost were performed, and all significant tumor, patient, and surgeon-specific variables were entered in a linear regression for cost. A separate linear regression was performed for length of stay (LOS). RESULTS In total, 59 patients underwent 61 CRS/HIPEC procedures. The median direct variable cost was $20,509 (16,395-25,240). Median length of stay (LOS) was 8 (7-11.5) days and ICU stay was 1 (1-1.5) day. LOS, length of ICU stay and operative time were predictive of cost. Factors associated with increased LOS were Clavien-Dindo grade II complications and ostomy creation. Patient-related factors, including age and BMI, tumor-related factors, such as PCI and CCR, and surgeon were not predictive of cost nor LOS. DISCUSSION Our results, the first to identify predictors of high cost of CRS/HIPEC-related care in the US, reveal cost was largely related to length and intensity of care. In turn, these drivers were influenced by complications and operative factors. Future work will focus on identifying an appropriate ERAS protocol following CRS/HIPEC and selection of those patients that may avoid routine ICU admission.
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Affiliation(s)
- Patrick B Schwartz
- Department of Surgery, Division of Surgical Oncology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Christopher C Stahl
- Department of Surgery, Division of Surgical Oncology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Kara A Vande Walle
- Department of Surgery, Division of Surgical Oncology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Courtney J Pokrzywa
- Department of Surgery, Division of Surgical Oncology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Linda M Cherney Stafford
- Department of Surgery, Division of Surgical Oncology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Taylor Aiken
- Department of Surgery, Division of Surgical Oncology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - James Barrett
- Department of Surgery, Division of Surgical Oncology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Alexandra W Acher
- Department of Surgery, Division of Surgical Oncology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Glen Leverson
- Department of Surgery, Division of Surgical Oncology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Sean Ronnekleiv-Kelly
- Department of Surgery, Division of Surgical Oncology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Sharon M Weber
- Department of Surgery, Division of Surgical Oncology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Daniel E Abbott
- Department of Surgery, Division of Surgical Oncology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.
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21
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Aiken T, Barrett J, Stahl CC, Schwartz PB, Udani S, Acher AW, Leverson G, Abbott D. Operative Delay in Adults with Appendicitis: Time is Money. J Surg Res 2020; 253:232-237. [PMID: 32387570 DOI: 10.1016/j.jss.2020.03.038] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 02/28/2020] [Accepted: 03/10/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Evidence suggests that operative delay of up to 24 h is not associated with adverse outcomes among patients undergoing emergent appendectomy. However, the fiscal implication of operative delay is not well described in adults. We sought to examine the effect of delayed appendectomy on clinical outcomes and hospital cost. METHODS We conducted a retrospective cohort study of patients undergoing nonelective laparoscopic appendectomy from 2014 to 2018 at both a tertiary care center and an affiliated short-stay hospital. Using a unique data set constructed from merged electronic health record and patient-level hospital financial data, patients with delayed surgery, defined as >12 h from emergency department (ED) arrival to operation, were compared with patients who underwent surgery within 12 h. Patient-specific variables were analyzed for their association with resource utilization, and subsequent multivariable linear regression was performed for total hospital cost. RESULTS 1372 patients underwent laparoscopic appendectomy during the study period. 938 patients (68.3%) underwent surgery within 12 h of ED arrival, and 434 patients (31.6%) underwent delayed surgery. Delayed cases had longer length of stay (44.6 ± 42.5 versus 34.5 ± 36.5 h, P < 0.01) and increased total hospital cost ($9326 ± 4691 versus $8440 ± 3404, P < 0.01). The cost difference persisted on multivariable analysis (P < 0.01). There were no significant differences between delayed cases and nondelayed cases for operative time, intraoperative findings, including rate of perforation, or postoperative complications. CONCLUSIONS Although safe, delayed appendectomy is associated with an increased length of stay and increased total hospital costs compared with appendectomy within 12 h of reaching the ED.
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Affiliation(s)
- Taylor Aiken
- Department of Surgery, University of Wisconsin Hospitals and Clinics, Madison, Wisconsin
| | - James Barrett
- Department of Surgery, University of Wisconsin Hospitals and Clinics, Madison, Wisconsin
| | - Christopher C Stahl
- Department of Surgery, University of Wisconsin Hospitals and Clinics, Madison, Wisconsin
| | - Patrick B Schwartz
- Department of Surgery, University of Wisconsin Hospitals and Clinics, Madison, Wisconsin
| | - Shreyans Udani
- School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
| | - Alexandra W Acher
- Department of Surgery, University of Wisconsin Hospitals and Clinics, Madison, Wisconsin
| | - Glen Leverson
- Department of Surgery, University of Wisconsin Hospitals and Clinics, Madison, Wisconsin
| | - Daniel Abbott
- Department of Surgery, University of Wisconsin Hospitals and Clinics, Madison, Wisconsin
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22
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Stahl CC, Schwartz PB, Leverson GE, Barrett JR, Aiken T, Acher AW, Ronnekleiv-Kelly SM, Minter RM, Weber SM, Abbott DE. Summary perioperative risk metrics within the electronic medical record predict patient-level cost variation in pancreaticoduodenectomy. Surgery 2020; 168:274-279. [PMID: 32349869 DOI: 10.1016/j.surg.2020.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 01/30/2020] [Accepted: 03/06/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Automated data extraction from the electronic medical record is fast, scalable, and inexpensive compared with manual abstraction. However, concerns regarding data quality and control for underlying patient variation when performing retrospective analyses exist. This study assesses the ability of summary electronic medical record metrics to control for patient-level variation in cost outcomes in pancreaticoduodenectomy. METHODS Patients that underwent pancreaticoduodenectomy from 2014 to 2018 at a single institution were identified within the electronic medical record and linked with the National Surgical Quality Improvement Program. Variables in both data sets were compared using interrater reliability. Logistic and linear regression modelling of complications and costs were performed using combinations of comorbidities/summary metrics. Models were compared using the adjusted R2 and Akaike information criterion. RESULTS A total of 117 patients populated the final data set. A total of 31 (26.5%) patients experienced a complication identified by the National Surgical Quality Improvement Program. The median direct variable cost for the encounter was US$14,314. Agreement between variables present in the electronic medical record and the National Surgical Quality Improvement Program was excellent. Stepwise linear regression models of costs, using only electronic medical record-extractable variables, were non-inferior to those created with manually abstracted individual comorbidities (R2 = 0.67 vs 0.30, Akaike information criterion 2,095 vs 2,216). Model performance statistics were minimally impacted by the addition of comorbidities to models containing electronic medical record summary metrics (R2 = 0.67 vs 0.70, Akaike information criterion 2,095 vs 2,088). CONCLUSION Summary electronic medical record perioperative risk metrics predict patient-level cost variation as effectively as individual comorbidities in the pancreaticoduodenectomy population. Automated electronic medical record data extraction can expand the patient population available for retrospective analysis without the associated increase in human and fiscal resources that manual data abstraction requires.
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Affiliation(s)
- Christopher C Stahl
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Patrick B Schwartz
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Glen E Leverson
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - James R Barrett
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Taylor Aiken
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Alexandra W Acher
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Sean M Ronnekleiv-Kelly
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Rebecca M Minter
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Sharon M Weber
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Daniel E Abbott
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI.
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23
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Stahl CC, Rosser AA, Jung SJ, Minter RM, Greenberg JA. Integration of Entrustable Professional Activities into General Surgery Residency: A Practical Guide. J Am Coll Surg 2019. [DOI: 10.1016/j.jamcollsurg.2019.08.534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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24
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Kim Y, Stahl CC, Makramalla A, Olowokure OO, Ristagno RL, Dhar VK, Schoech MR, Chadalavada S, Latif T, Kharofa J, Bari K, Shah SA. Downstaging therapy followed by liver transplantation for hepatocellular carcinoma beyond Milan criteria. Surgery 2017; 162:1250-1258. [PMID: 29033224 DOI: 10.1016/j.surg.2017.08.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Revised: 08/03/2017] [Accepted: 08/16/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Orthotopic liver transplantation is a curative treatment for hepatocellular carcinoma within Milan criteria, but these criteria preclude many patients from transplant candidacy. Recent studies have demonstrated that downstaging therapy can reduce tumor burden to meet conventional criteria. The present study reports a single-center experience with tumor downstaging and its effects on post-orthotopic liver transplantation outcomes. METHODS All patients with hepatocellular carcinoma who were evaluated by our multidisciplinary liver services team from 2012 to 2016 were identified (N = 214). Orthotopic liver transplantation candidates presenting outside of Milan criteria at initial radiographic diagnosis and/or an initial alpha-fetoprotein >400 ng/mL were categorized as at high risk for tumor recurrence and post-transplant mortality. RESULTS Of the 214 patients newly diagnosed with hepatocellular carcinoma, 73 (34.1%) eventually underwent orthotopic liver transplantation. The majority of patients who did not undergo orthotopic liver transplantation were deceased or lost to follow-up (47.5%), with 14 of 141 (9.9%) currently listed for transplantation. Among transplanted patients, 21 of 73 (28.8%) were considered high-risk candidates. All 21 patients were downstaged to within Milan criteria with an alpha-fetoprotein <400 ng/mL before orthotopic liver transplantation, through locoregional therapies. Recurrence of hepatocellular carcinoma was higher but acceptable between downstaged high-risk and traditional candidates (9.5% vs 1.9%; P > .05) at a median follow-up period of 17 months. Downstaged high-risk candidates had a similar overall survival compared with those transplanted within Milan criteria (log-rank P > .05). CONCLUSIONS In highly selected cases, patients with hepatocellular carcinoma outside of traditional criteria for orthotopic liver transplantation may undergo downstaging therapy in a multidisciplinary fashion with excellent post-transplant outcomes. These data support an aggressive downstaging approach for selected patients who would otherwise be deemed ineligible for transplantation.
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Affiliation(s)
- Young Kim
- University of Cincinnati Liver Malignancy Working Group, University of Cincinnati College of Medicine, Cincinnati Research in Outcomes and Safety in Surgery, Cincinnati, OH; Department of Surgery, University of Cincinnati College of Medicine, Cincinnati Research in Outcomes and Safety in Surgery, Cincinnati, OH
| | - Christopher C Stahl
- University of Cincinnati Liver Malignancy Working Group, University of Cincinnati College of Medicine, Cincinnati Research in Outcomes and Safety in Surgery, Cincinnati, OH
| | - Abouelmagd Makramalla
- University of Cincinnati Liver Malignancy Working Group, University of Cincinnati College of Medicine, Cincinnati Research in Outcomes and Safety in Surgery, Cincinnati, OH; Department of Radiology, University of Cincinnati College of Medicine, Cincinnati Research in Outcomes and Safety in Surgery, Cincinnati, OH
| | - Olugbenga O Olowokure
- University of Cincinnati Liver Malignancy Working Group, University of Cincinnati College of Medicine, Cincinnati Research in Outcomes and Safety in Surgery, Cincinnati, OH; Department of Medicine, University of Cincinnati College of Medicine, Cincinnati Research in Outcomes and Safety in Surgery, Cincinnati, OH
| | - Ross L Ristagno
- University of Cincinnati Liver Malignancy Working Group, University of Cincinnati College of Medicine, Cincinnati Research in Outcomes and Safety in Surgery, Cincinnati, OH; Department of Radiology, University of Cincinnati College of Medicine, Cincinnati Research in Outcomes and Safety in Surgery, Cincinnati, OH
| | - Vikrom K Dhar
- University of Cincinnati Liver Malignancy Working Group, University of Cincinnati College of Medicine, Cincinnati Research in Outcomes and Safety in Surgery, Cincinnati, OH; Department of Surgery, University of Cincinnati College of Medicine, Cincinnati Research in Outcomes and Safety in Surgery, Cincinnati, OH
| | - Michael R Schoech
- University of Cincinnati Liver Malignancy Working Group, University of Cincinnati College of Medicine, Cincinnati Research in Outcomes and Safety in Surgery, Cincinnati, OH; Department of Medicine, University of Cincinnati College of Medicine, Cincinnati Research in Outcomes and Safety in Surgery, Cincinnati, OH
| | - Seetharam Chadalavada
- University of Cincinnati Liver Malignancy Working Group, University of Cincinnati College of Medicine, Cincinnati Research in Outcomes and Safety in Surgery, Cincinnati, OH; Department of Radiology, University of Cincinnati College of Medicine, Cincinnati Research in Outcomes and Safety in Surgery, Cincinnati, OH
| | - Tahir Latif
- University of Cincinnati Liver Malignancy Working Group, University of Cincinnati College of Medicine, Cincinnati Research in Outcomes and Safety in Surgery, Cincinnati, OH; Department of Medicine, University of Cincinnati College of Medicine, Cincinnati Research in Outcomes and Safety in Surgery, Cincinnati, OH
| | - Jordan Kharofa
- University of Cincinnati Liver Malignancy Working Group, University of Cincinnati College of Medicine, Cincinnati Research in Outcomes and Safety in Surgery, Cincinnati, OH; Department of Radiation Oncology, University of Cincinnati College of Medicine, Cincinnati Research in Outcomes and Safety in Surgery, Cincinnati, OH
| | - Khurram Bari
- University of Cincinnati Liver Malignancy Working Group, University of Cincinnati College of Medicine, Cincinnati Research in Outcomes and Safety in Surgery, Cincinnati, OH; Department of Medicine, University of Cincinnati College of Medicine, Cincinnati Research in Outcomes and Safety in Surgery, Cincinnati, OH
| | - Shimul A Shah
- University of Cincinnati Liver Malignancy Working Group, University of Cincinnati College of Medicine, Cincinnati Research in Outcomes and Safety in Surgery, Cincinnati, OH; Department of Surgery, University of Cincinnati College of Medicine, Cincinnati Research in Outcomes and Safety in Surgery, Cincinnati, OH.
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25
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Stahl CC, Moulton J, Vu D, Ristagno R, Choe K, Sussman JJ, Shah SA, Ahmad SA, Abbott DE. Routine use of U-tube drainage for necrotizing pancreatitis: a step toward less morbidity and resource utilization. Surgery 2015; 158:919-26; discussion 926-8. [PMID: 26271525 DOI: 10.1016/j.surg.2015.07.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Revised: 06/24/2015] [Accepted: 07/07/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND A U-tube drainage catheter (UTDC) is a novel intervention for necrotizing pancreatitis, with multiple benefits: bidirectional flushing, greater interface with large fluid collections, less risk of dislodgement, and creation of a large-diameter fistula tract for potential fistulojejunostomy. We report the first clinical experience with UTDC for necrotizing pancreatitis. METHODS From 2011 to 2014, all patients undergoing UTDC for necrotizing pancreatitis at our institution were identified. Clinical variables including patient, disease, and intervention-specific characteristics as well as long-term outcomes populated our dataset. RESULTS Twenty-two patients underwent UTDC for necrotizing pancreatitis; the median follow-up was 10.2 months. Necrotizing pancreatitis was most commonly owing to gallstones (n = 9; 41%), idiopathic disease (n = 5; 23%), and alcohol abuse (n = 4; 18%). During the course of UTDC and definitive operative therapy (when required), patients had median hospital stays of 31 days, 6 interventional radiology procedures, and 6 CT scans. Operative intervention was not necessary in 9 patients (41%). Among the other 13 patients, 4 patients underwent distal pancreatectomy/splenectomy, 8 had a fistulojejunostomy performed, and 1 underwent both procedures. CONCLUSION UTDC for necrotizing pancreatitis patients is associated with effective drainage and low morbidity/hospital resource utilization. With skilled interventional radiologists and multidisciplinary coordination, this technique is a valuable means of minimizing morbidity for patients with necrotizing pancreatitis.
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Affiliation(s)
| | - Jonathan Moulton
- Department of Radiology, University of Cincinnati, Cincinnati, OH
| | - Doan Vu
- Department of Radiology, University of Cincinnati, Cincinnati, OH
| | - Ross Ristagno
- Department of Radiology, University of Cincinnati, Cincinnati, OH
| | - Kyuran Choe
- Department of Radiology, University of Cincinnati, Cincinnati, OH
| | | | - Shimul A Shah
- Department of Surgery, University of Cincinnati, Cincinnati, OH
| | - Syed A Ahmad
- Department of Surgery, University of Cincinnati, Cincinnati, OH
| | - Daniel E Abbott
- Department of Surgery, University of Cincinnati, Cincinnati, OH.
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26
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Stahl CC, Wima K, Hanseman DJ, Hoehn RS, Ertel A, Midura EF, Hohmann SF, Paquette IM, Shah SA, Abbott DE. Organ quality metrics are a poor predictor of costs and resource utilization in deceased donor kidney transplantation. Surgery 2015; 158:1635-41. [PMID: 26096564 DOI: 10.1016/j.surg.2015.05.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2014] [Revised: 05/03/2015] [Accepted: 05/20/2015] [Indexed: 11/24/2022]
Abstract
BACKGROUND The desire to provide cost-effective care has lead to an investigation of the costs of therapy for end-stage renal disease. Organ quality metrics are one way to attempt to stratify kidney transplants, although the ability of these metrics to predict costs and resource use is undetermined. METHODS The Scientific Registry of Transplant Recipients database was linked to the University HealthSystem Consortium Database to identify adult deceased donor kidney transplant recipients from 2009 to 2012. Patients were divided into cohorts by kidney criteria (standard vs expanded) or kidney donor profile index (KDPI) score (<85 vs 85+). Length of stay, 30-day readmission, discharge disposition, and delayed graft function were used as indicators of resource use. Cost was defined as reimbursement based on Medicare cost/charge ratios and included the costs of readmission when applicable. RESULTS More than 19,500 patients populated the final dataset. Lower-quality kidneys (expanded criteria donor or KDPI 85+) were more likely to be transplanted in older (both P < .001) and diabetic recipients (both P < .001). After multivariable analysis controlling for recipient characteristics, we found that expanded criteria donor transplants were not associated with increased costs compared with standard criteria donor transplants (risk ratio [RR] 0.97, 95% confidence interval [CI] 0.93-1.00, P = .07). KDPI 85+ was associated with slightly lower costs than KDPI <85 transplants (RR 0.95, 95% CI 0.91-0.99, P = .02). When KDPI was considered as a continuous variable, the association was maintained (RR 0.9993, 95% CI 0.999-0.9998, P = .01). CONCLUSION Organ quality metrics are less influential predictors of short-term costs than recipient factors. Future studies should focus on recipient characteristics as a way to discern high versus low cost transplantation procedures.
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Affiliation(s)
- Christopher C Stahl
- Cincinnati Research in Outcomes and Safety in Surgery, Department of Surgery, University of Cincinnati, Cincinnati, OH
| | - Koffi Wima
- Cincinnati Research in Outcomes and Safety in Surgery, Department of Surgery, University of Cincinnati, Cincinnati, OH
| | - Dennis J Hanseman
- Cincinnati Research in Outcomes and Safety in Surgery, Department of Surgery, University of Cincinnati, Cincinnati, OH
| | - Richard S Hoehn
- Cincinnati Research in Outcomes and Safety in Surgery, Department of Surgery, University of Cincinnati, Cincinnati, OH
| | - Audrey Ertel
- Cincinnati Research in Outcomes and Safety in Surgery, Department of Surgery, University of Cincinnati, Cincinnati, OH
| | - Emily F Midura
- Cincinnati Research in Outcomes and Safety in Surgery, Department of Surgery, University of Cincinnati, Cincinnati, OH
| | | | - Ian M Paquette
- Cincinnati Research in Outcomes and Safety in Surgery, Department of Surgery, University of Cincinnati, Cincinnati, OH
| | - Shimul A Shah
- Cincinnati Research in Outcomes and Safety in Surgery, Department of Surgery, University of Cincinnati, Cincinnati, OH
| | - Daniel E Abbott
- Cincinnati Research in Outcomes and Safety in Surgery, Department of Surgery, University of Cincinnati, Cincinnati, OH.
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Stahl CC, Hanseman DJ, Wima K, Sutton JM, Wilson GC, Hohmann SF, Shah SA, Abbott DE. Increasing age is a predictor of short-term outcomes in esophagectomy: a propensity score adjusted analysis. J Gastrointest Surg 2014; 18:1423-8. [PMID: 24866369 PMCID: PMC7065666 DOI: 10.1007/s11605-014-2544-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2014] [Accepted: 05/13/2014] [Indexed: 01/31/2023]
Abstract
BACKGROUND Esophagectomy is a high-risk surgical procedure. As the population ages, more elderly candidates are being evaluated for esophagectomy. The effects of patient age on outcomes after esophagectomy need to be evaluated. STUDY DESIGN We identified all nonemergent esophagectomies in patients at least 18 years of age within the University HealthSystems Consortium Clinical Database/Resource Manager from 2009 to 2012. Using univariate and multivariate methods, the impact of increasing age on outcomes was analyzed. Additionally, propensity scoring was used to match patients to further investigate the effect of age on the stated outcomes. RESULTS Increasing age is associated with increased mortality (p < 0.001), length of stay (p < 0.001), discharge to rehabilitative care (p < 0.001), and cost (p < 0.001). The effects of age on mortality (8.0 vs 4.2 %, p = 0.03) and discharge to rehabilitative care (44.1 vs 23.4 %, p < 0.01) were confirmed using propensity scoring, comparing patients above 80 with those age 70-79. CONCLUSIONS Increasing age has a significant impact on outcomes following esophagectomy, particularly mortality and discharge disposition. Compared to patients under age 80, patients at least 80 years of age considering esophagectomy should be recognized as a high-risk cohort, and these patients must be carefully risk-stratified, counseled, and selected for surgical intervention to prevent unnecessary hospitalization and mortality.
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Affiliation(s)
- Christopher C. Stahl
- Cincinnati Research in Outcomes and Safety in Surgery, Department of Surgery, University of Cincinnati, 234 Goodman St, ML 0772, Cincinnati, OH 45219, USA
| | - Dennis J. Hanseman
- Cincinnati Research in Outcomes and Safety in Surgery, Department of Surgery, University of Cincinnati, 234 Goodman St, ML 0772, Cincinnati, OH 45219, USA
| | - Koffi Wima
- Cincinnati Research in Outcomes and Safety in Surgery, Department of Surgery, University of Cincinnati, 234 Goodman St, ML 0772, Cincinnati, OH 45219, USA
| | - Jeffrey M. Sutton
- Cincinnati Research in Outcomes and Safety in Surgery, Department of Surgery, University of Cincinnati, 234 Goodman St, ML 0772, Cincinnati, OH 45219, USA
| | - Gregory C. Wilson
- Cincinnati Research in Outcomes and Safety in Surgery, Department of Surgery, University of Cincinnati, 234 Goodman St, ML 0772, Cincinnati, OH 45219, USA
| | | | - Shimul A. Shah
- Cincinnati Research in Outcomes and Safety in Surgery, Department of Surgery, University of Cincinnati, 234 Goodman St, ML 0772, Cincinnati, OH 45219, USA
| | - Daniel E. Abbott
- Cincinnati Research in Outcomes and Safety in Surgery, Department of Surgery, University of Cincinnati, 234 Goodman St, ML 0772, Cincinnati, OH 45219, USA
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