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Gastroesophageal Reflux Disease (GERD) is an extremely common condition with several medical and surgical treatment options. A multidisciplinary expert panel was convened to develop evidence-based recommendations to support clinicians, patients, and others in decisions regarding the treatment of GERD with an emphasis on evaluating different surgical techniques. Literature reviews were conducted for 4 key questions regarding the surgical treatment of GERD in both adults and children: surgical vs. medical treatment, robotic vs. laparoscopic fundoplication, partial vs. complete fundoplication, and division vs. preservation of short gastric vessels in adults or maximal versus minimal dissection in pediatric patients. Evidence-based recommendations were formulated using the GRADE methodology by subject experts. Recommendations for future research were also proposed. The panel provided seven recommendations for adults and children with GERD. All recommendations were conditional due to very low, low, or moderate certainty of evidence. The panel conditionally recommended surgical treatment over medical management for adults with chronic or chronic refractory GERD. There was insufficient evidence for the panel to make a recommendation regarding surgical versus medical treatment in children. The panel suggested that once the decision to pursue surgical therapy is made, adults and children with GERD may be treated with either a robotic or a laparoscopic approach, and either partial or complete fundoplication based on surgeon–patient shared decision-making and patient values. In adults, the panel suggested either division or non-division of the short gastric vessels is appropriate, and that children should undergo minimal dissection during fundoplication. These recommendations should provide guidance with regard to surgical decision-making in the treatment of GERD and highlight the importance of shared decision-making and patient values to optimize patient outcomes. Pursuing the identified research needs may improve future versions of guidelines for the treatment of GERD.

Background Variable approaches to intraoperative communication impede our understanding of surgical decision-making and best practices. This is critical among hernia repairs, where improved outcomes are reliant on understanding the impact of different patient characteristics and surgical approaches. In this context, a hernia-specific synoptic operative note was piloted as part of an effort to create a statewide hernia registry. We aimed to understand the impact of the synoptic operative note on variable missingness and evaluate barriers and facilitators to improved intraoperative communication and note adoption. Methods In January 2020, the Michigan Surgical Quality Collaborative (MSQC) registry was expanded to capture hernia-specific intraoperative variables. A synoptic operative note for hernia repair was piloted at 8 hospitals. The primary outcome was change in hernia variable communication, measured by missingness. Using a sequential explanatory mixed-methods design, we performed semi-structured interviews with data abstractors (n = 4) and surgeons (n = 4) at 5 pilot sites to assess barriers and facilitators of implementation. Interviews were iteratively analyzed using content analysis with both deductive and inductive approaches. Results From January to June 2020, 870 hernia repairs were performed across 8 pilot and 53 control sites. Pilot sites had significantly less missingness for all hernia-specific variables. At pilot sites, 46% of notes were fully complete in regard to hernia variables, compared to 21% at control sites (p value

Background Telehealth may be an important care delivery modality in reducing dropout from bariatric surgery programs which is reported globally at approximately 50%. Methods In this convergent mixed methods case study of a large, US healthcare system, we examine the impact of telehealth implementation in 2020 on pre-operative bariatric surgery visits and provider perspectives of telehealth use. Results We find that telehealth was significantly associated with a 38% reduction in no-show rate compared with the prior year. Additionally, providers had positive experiences with regard to the appropriateness and feasibility of using telehealth in the pre-operative bariatric surgery process. Conclusions Telehealth use in the pre-operative bariatric surgery process may lead to greater efficiency in healthcare resource utilization. Insurance providers and bariatric accreditation bodies globally should consider accepting telehealth visits and self-reported weights when determining coverage decisions to ensure access for patients.

Hiatal hernia repair performed at the time of laparoscopic sleeve gastrectomy (LSG) may reduce post-operative reflux symptoms. It is unclear whether intra-operative diagnosis of hiatal hernia varies among surgeons or if it affects outcomes. Surgeons (n = 38) participating in a statewide bariatric surgery quality improvement collaborative reviewed 33 videos of LSG in which no hiatal hernia repair was performed. Reviewers were blinded to patient information and were asked whether they perceived a hiatal hernia. Surgeon characteristics and surgeon-specific patient outcomes for LSG were compared between surgeons who identified at least one hiatal hernia during video review and those who did not. Ten surgeons (26%) identified at least one hiatal hernia after reviewing the videos. There were no significant differences in operative experience or practice type between surgeons who did and did not identify hiatal hernias. Surgeons who identified a hiatal hernia more often performed concurrent hiatal hernia repair in their practice when compared to those who did not (43.0% versus 36.5%, p

Financial conflicts of interest (COI) have been shown to affect the interpretation of scientific findings. Publications with unreported COI tend to be more favorable to industry. Since 2014 industry payments to United States (US) physicians are publicly reported in the Open Payments Database (OPD). Several studies show high levels of unreported COI in medical literature; however, there is no research examining COI reporting at surgical conferences. We hypothesized that compliance with the COI disclosure requirement would be high at the 2018 SAGES meeting. However, we expected to find significant discrepancy between speaker-reported and OPD-reported COI. A secondary aim was to characterize the amount, source, and variation in industry payments to invited speakers. We reviewed all available presentations from SAGES 2018 as recorded and publicly available on YouTube™ for the presence of COI disclosure and the disclosed industry relationships. For US physicians we searched the OPD and recorded all industry payments > $500. We compared the self-disclosed COI for each speaker with OPD records. Presentation topics were divided into ten groups to determine which topics received the most funding. Of the 526 invited presentations, 479 (91%) videos were available. Disclosures were reported by 414 presenters (86.4%). There were 420 unique presenters of which 315 were listed in the OPD. Speaker-reported disclosures were fully concordant with the OPD in 38.3% (121/315) of cases with 39% (123/315) under-reporting disclosures. Of presenters listed in OPD, the median payment was $992 ($0–$374,502) with a total of $6,389,097 paid in 2017. SAGES speakers failed to disclose $2,049,535 worth of industry payments with an average undisclosed payment of $16,662.88 (± $40,733.19). The largest financial contributor was Intuitive Surgical with $1,981,169 paid. Among topics, robotics and hernia received the most funding with $2,593,925 (40.6%) and $2,591,671 (40.5%) paid, respectively. Overall compliance with SAGES disclosure rules is high. There remains a discrepancy between speaker- and industry-reported disclosures, including a number of undisclosed payments, some of which are substantial. Adjustments to disclosure rules to include the relative amount of compensation may be warranted.

Although ventral hernia repair (VHR) is extremely common, there is profound variation in operative technique and outcomes. This study describes the results of a statewide registry capturing hernia-specific variables to understand population-level practice patterns.Retrospective analysis of adult patients in a new statewide hernia registry undergoing VHR in 2020.919 patients underwent VHR across 57 hospitals and 279 surgeons. Hernia width was2 cm in 233 (25%) patients, 2-5 cm in 420 (46%) patients, 5-10 cm in 171 (19%) patients, and10 cm in 95 (10%) patients. Mesh was used in 79% of cases and varied in use from 53% of hernias2 cm to 95% of hernias10 cm. The most common mesh type was synthetic non-absorbable (46%), followed by synthetic absorbable mesh (37%). The incidence of complications was significantly associated with hernia width.A population-level, hernia-specific database captured operative details for 919 patients in 1 year. There was significant variation in mesh use and outcomes based on hernia size. These nuanced data may inform higher quality clinical practice.

OBJECTIVE To describe post-acute care (PAC) utilization and associated payments for patients undergoing common elective procedures. SUMMARY BACKGROUND DATA Utilization and costs of PAC are well described for benchmarked conditions and operations but remain understudied for common elective procedures. METHODS Cross-sectional study of adult patients in a statewide administrative claims database undergoing elective cholecystectomy, ventral or incisional hernia repair (VIHR), and groin hernia repair from 2012-2019. We used multivariable logistic regression to estimate the odds of PAC utilization, and multivariable linear regression to determine the association of 90-day episode of care payments and PAC utilization. RESULTS Among 34,717 patients undergoing elective cholecystectomy, 0.7% utilized PAC resulting in significantly higher payments ($19,047 vs $7,830, p < 0.001). Among 29,826 patients undergoing VIHR, 1.7% utilized PAC resulting in significantly higher payments ($19,766 vs $9,439, p < 0.001). Among 37,006 patients undergoing groin hernia repair, 0.3% utilized PAC services resulting in significantly higher payments ($14,886 vs $8,062, p < 0.001). We found both modifiable and non-modifiable risk factors associated with PAC utilization. Morbid obesity was associated with PAC utilization following VIHR (OR 1.61, 95% CI 1.29-2.02, p < 0.001). Male sex was associated with lower odds of PAC utilization for VIHR (OR 0.43, 95% CI 0.35-0.51, p < 0.001) and groin hernia repair (OR 0.62, 95% CI 0.39-0.98, p = 0.039). CONCLUSIONS We found both modifiable (e.g. obesity) and non-modifiable (e.g. female sex) patient factors that were associated with PAC. Optimizing patients to reduce PAC utilization requires an understanding of patient risk factors as well as systems and processes to address these factors.

To assess patient-reported gastroesophageal reflux disease (GERD) severity before and after SG and Roux-en-Y gastric bypass (RYGB).Development of new-onset or worsening GERD symptoms after bariatric surgery varies by procedure, but there is a lack of patient-reported data to help guide decision-making. Methods: Retrospective cohort study of patients undergoing bariatric surgery in a statewide quality collaborative between 2013 and 2017. We used a validated GERD survey with symptom scores ranging from 0 (no symptoms) to 5 (severe daily symptoms) and included patients who completed surveys both at baseline and 1-year after surgery (n = 10,451). We compared the rates of improved and worsened GERD symptoms after SG and RYGB.Within our study cohort, 8680 (83%) underwent SG and 1771 (17%) underwent RYGB. Mean baseline score for all patients was 0.94. Patients undergoing SG experienced similar improvement in GERD symptoms when compared to RYGB (30.4% vs 30.8%, P = 0.7015). However, SG patients also reported higher rates of worsening symptoms (17.8% vs 7.5%, P0.0001) even though they were more likely to undergo concurrent hiatal hernia repair (35.1% vs 20.0%, P0.0001). More than half of patients (53.5%) did not report a change in their score.Although SG patients reported higher rates of worsening GERD symptoms when compared to RYGB, the majority of patients (80%) in this study experienced improvement or no change in GERD regardless of procedure. Using clinically relevant patient-reported outcomes can help guide decisions about procedure choice in bariatric surgery for patients with GERD.

BACKGROUND: Opioid use after bariatric surgery is not clearly understood. Few guidelines exist to inform opioid prescribing practices after bariatric surgery. OBJECTIVE: To understand opioid use following bariatric surgery. SETTING: University Hospital. METHODS: Bariatric surgery patients at a single center were prospectively surveyed at the time of their post-operative visit (January-May 2018). Patients were asked about their opioid use following surgery, whether they received education about opioid use, and what they did with leftover medications. Demographic and operative details were obtained from the medical record. RESULTS: Among 33 patients, the majority (n=29, 88%) were female with a median age of 40 (20–68) and body mass index of 44.8 (33–78.5). Most patients had leftover narcotics (n=25, 73%). The median number of pills used was 15 (0–48). Only 12 patients (36%) thought that they had been prescribed “too much” pain medication. Most patients reported receiving education about expectations for post-operative pain (n=22, 69%); few recalled education about reducing or stopping opioids (n=13, 40%). More than half of patients (n=17, 53%) kept their leftover opioids rather than disposing of them or bringing them to an approved turn in location. CONCLUSIONS: Despite most patients having leftover opioids following surgery, few patients recognized possible over prescription. Education regarding opioid use following surgery is inconsistent, potentially contributing to the amount of retained opioids currently available. Future guidelines should focus on determining the appropriate amount of opioids to be prescribed following surgery and standardizing and improving education given to patients.

IMPORTANCE: Additional data comparing longer-term problems associated with various bariatric surgical procedures are needed for shared decision-making. OBJECTIVE: To compare the risks of intervention, operation, endoscopy, hospitalization, and mortality up to 5 years after 2 bariatric surgical procedures. DESIGN, SETTING, AND PARTICIPANTS: Adults who underwent Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) between January 1, 2005, and September 30, 2015, within the National Patient-Centered Clinical Research Network. Data from 33 560 adults at 10 centers within 4 clinical data research networks were included in this cohort study. Information was extracted from electronic health records using a common data model and linked to insurance claims and mortality indices. Analyses were conducted from January 2018 through October 2019. EXPOSURES: Bariatric surgical procedures. MAIN OUTCOMES AND MEASURES: The primary outcome was time until operation or intervention. Secondary outcomes included endoscopy, hospitalization, and mortality rates. RESULTS: Of 33 560 adults, 18 056 (54%) underwent RYGB, and 15 504 (46%) underwent SG. The median (interquartile range) follow-up for operation or intervention was 3.4 (1.6-5.0) years for RYGB and 2.2 (0.9-3.6) years for SG. The overall mean (SD) patient age was 45.0 (11.5) years, and the overall mean (SD) patient body mass index was 49.1 (7.9). The cohort was composed predominantly of women (80%) and white individuals (66%), with 26% of Hispanic ethnicity. Operation or intervention was less likely for SG than for RYGB (hazard ratio, 0.72; 95% CI, 0.65-0.79; P

Key Points Question Can a low-cost optimization clinic be implemented to successfully manage high-risk patients seeking hernia repair? Findings In this quality improvement study, 1 year after the implementation of a preoperative optimization clinic, 9.1% of high-risk patients became eligible for hernia repair through the optimization of a high-risk characteristic, and the number of emergency surgery events was low. Meaning These findings suggest that this model represents a scalable and sustainable framework for preoperative optimization with the potential to improve the care of patients with hernias., This quality improvement study evaluates the feasibility of a low-cost preoperative optimization clinic that was implemented to improve the care of high-risk patients seeking elective hernia repair., Importance Preoperative optimization is an important clinical strategy for reducing morbidity; however, nearly 25% of persons undergoing elective abdominal hernia repairs are not optimized with respect to weight or substance use. Although the preoperative period represents a unique opportunity to motivate patient health behavior changes, fear of emergent presentation and financial concerns are often cited as clinician barriers to optimization. Objective To evaluate the feasibility of evidence-based patient optimization before surgery by implementing a low-cost preoperative optimization clinic. Design, Setting, and Participants This quality improvement study was conducted 1 year after a preoperative optimization clinic was implemented for high-risk patients seeking elective hernia repair. The median (range) follow-up was 197 (39-378) days. A weekly preoperative optimization clinic was implemented in 2019 at a single academic center. Referral occurred for persons seeking elective hernia repair with a body mass index greater than or equal to 40, age 75 years or older, or active tobacco use. Data analysis was performed from February to July 2020. Exposures Enrolled patients were provided health resources and longitudinal multidisciplinary care. Main Outcomes and Measures The primary outcomes were safety and eligibility for surgery after participating in the optimization clinic. The hypothesis was that the optimization clinic could preoperatively mitigate patient risk factors, without increasing patient risk. Safety was defined as the occurrence of complications during participation in the optimization clinic. The secondary outcome metric centered on the financial impact of implementing the preoperative optimization program. Results Of the 165 patients enrolled in the optimization clinic, most were women (90 patients [54.5%]) and White (145 patients [87.9%]). The mean (SD) age was 59.4 (15.8) years. Patients’ eligibility for the clinic was distributed across high-risk criteria: 37.0% (61 patients) for weight, 26.1% (43 patients) for tobacco use, and 23.6% (39 patients) for age. Overall, 9.1% of persons (15 patients) were successfully optimized for surgery, and tobacco cessation was achieved in 13.8% of smokers (8 patients). The rate of hernia incarceration requiring emergent surgery was 3.0% (5 patients). Economic evaluation found increased operative yield from surgical clinics, with a 58% increase in hernia-attributed relative value units without altering surgeon workflow. Conclusions and Relevance In this quality improvement study, a hernia optimization clinic safely improved management of high-risk patients and increased operative yield for the institution. This represents an opportunity to create sustainable and scalable models that provide longitudinal care and optimize patients to improve outcomes of hernia repair.

Among patients with acute appendicitis (AA), perforation is thought to be associated with symptom duration before treatment. Perforation rates vary between hospitals raising the possibility that some perforations are preventable. The factors that compel patients to present earlier or later are unknown but are critical in developing quality improvement interventions aimed at reducing perforation rates.The Appendicitis Patient Pre-Hospital Experience (APPE) Survey is a prospective study of adults and parents of children with AA in six hospitals participating in Washington State's Comparative Effectiveness Research Translation Network (CERTAIN). The APPE survey includes questions about symptom duration before presentation (late defined as24 h), predisposing characteristics, enabling factors, and need.Among 80 patients, perforation occurred more frequently in late presenters (44% versus 11%, P 0.01). Late presenters more frequently drove themselves to the hospital (64% versus 52%, P = 0.05) as opposed to relying on friends/family members and described their health behavior as "waiting it out" when something is wrong (71% versus 46%, P = 0.03). We found similar sociodemographics, clinical characteristics, health care utilization, optimism, health care trust, and risk taking between the two cohorts.Late presenters described reduced social support and a tendency to "wait it out" and had higher rates of perforation than early presenters. These characteristics have not been well-studied conditions but are important to understand to identify patients at high risk for delayed presentation. Future interventions might target those with low social support or those who are reluctant to seek care early to decrease rates of perforation.

Surgical site infection (SSI) after spine surgery is classified as a "never event" by the Centers for Medicare and Medicaid. Intra-wound antibiotics (IWA) have been proposed to reduce the incidence of SSI, but robust evidence to support its use is lacking.Prospective cohort undergoing spine fusion at 20 Washington State hospitals (July 2011 to March 2014) participating in the Spine Surgical Care and Outcomes Assessment Program (Spine SCOAP) linked to a discharge tracking system. Patient, hospital, and operative factors associated with SSI and IWA use during index hospitalizations through 600 days were analyzed using a random effects logistic model (index), and a time-to-event analysis (follow-up) using Cox proportional hazards.A total of 9,823 patients underwent cervical (47%) or lumbar (53%) procedures (mean age, 58; 54% female) with an SSI rate of 1.1% during index hospitalization. Those with SSI were older, more often had diabetes mellitus, and more frequently underwent lumbar (versus cervical) fusion compared with those without SSI (all p 0.01). Unadjusted rates of SSI during index hospitalization were lower in patients who received IWA (0.8% versus 1.5%). After adjustment for patient, hospital, and operative factors, no benefit was observed in those receiving IWA (odds ratio [OR] 0.65, 95% confidence interval [CI]: 0.42-1.03). At 12 mo, unadjusted rates of SSI were 2.4% and 3.0% for those who did and did not receive antibiotics; after adjustment there was no significant difference (hazard ratio [HR] 0.94, 95% CI: 0.62-1.42).Whereas unadjusted analyses indicate a nearly 50% reduction in index SSI using IWA, we did not observe a statistically significant difference after adjustment. Despite its size, this study is underpowered to detect small but potentially relevant improvements in rates of SSI. It remains to be determined if IWA should be promoted as a quality improvement intervention. Concerns related to bias in the use of IWA suggest the benefit of a randomized trial.

This qualitative study explores factors associated with surgeon choice of an open vs minimally invasive approach to inguinal hernia repair to better understand deviations from guidelines., Key Points Question What factors are associated with choice of approach (open vs minimally invasive) for inguinal hernia repair? Findings In this qualitative study of 21 practicing surgeons who perform abdominal wall hernia repairs, surgeon preference and autonomy, access and resources, and patient characteristics influenced the approach used for inguinal hernia repair surgery. Meaning Addressing surgeon preference and available resources may provide an opportunity to optimize care for patients undergoing inguinal hernia repair, while understanding these motivations may also inform questions of guideline-discordant care more broadly in surgery., Importance Despite availability of evidence-based guidelines for surgery, many patients receive guideline-discordant care. Reasons for this are largely unknown. For example, evidence-based guidelines recommend a minimally invasive approach for persons with bilateral or recurrent unilateral inguinal hernias. Benefits are also noted for primary unilateral inguinal hernia. However, findings from previous quantitative research indicate that only 26% of patients receive this treatment and only 42% of surgeons offer a minimally invasive approach, even for recurrent or bilateral hernias. Objective To explore factors associated with surgeon choice of approach (minimally invasive vs open) in inguinal hernia repair as a tool to gain an understanding of guideline-discordant care. Design, Setting, and Participants Qualitative study performed as part of a larger explanatory sequential mixed methods design. Purposive sampling was used to recruit 21 practicing surgeons from a large statewide quality collaborative who were diverse with regard to practice type, geographic location, and surgical specialty. Qualitative interviews consisted of a clinical vignette, followed by semi-structured interview questions. Through thematic analysis using qualitive data analysis software, patterns within the data were located, analyzed, and identified. All data were collected between April 24 and July 31, 2018. Exposure Clinical vignette as part of the qualitative interviews. Main Outcomes and Measures Capture of surgical approaches and factors motivating decision-making for inguinal hernia repair. Results Of the 21 participating surgeons, 17 (81%) were men, 18 (86%) were White, and all were 35 years of age or older. Data revealed 3 dominant themes: surgeon preference and autonomy (eg, favoring one approach over the other), access and resources (eg, availability of robot), and patient characteristics (eg, age, comorbidities). Conclusions and Relevance Decision-making for the approach to inguinal hernia repair is largely influenced by surgeon preference and access to resources rather than patient factors. Although a one-size-fits-all approach is not recommended, the operative approach should ideally be informed by patient factors, including hernia characteristics. Addressing surgeon preference and available resources with a clinician-facing decision aid may provide an opportunity to optimize care for patients undergoing inguinal hernia repair.

Key Points Question How can implementation frameworks such as the Theoretical Domains Framework be used to identify domains associated with the adoption of best practices in surgery? Findings This qualitative study used abdominal wall hernia as a case study and found that the surgeon knowledge, beliefs about the consequences, social or professional role and identity, environmental context and resources, and social influences domains were associated with decision-making. Meaning These findings suggest that implementation frameworks offer a method for better understanding which factors motivate behavior change among surgeons., This qualitative study evaluates the systematic application of the Theoretical Domains Framework to explore motivations and behaviors associated with surgical decision-making in abdominal wall hernia practice., Importance Although evidence-based guidelines designed to minimize health care variation and promote effective care are widely accepted, creating guidelines alone does not often lead to the desired practice change. Such knowledge-to-practice gaps are well-recognized in the management of patients with abdominal wall hernia, where wide variation in patient selection and operative approach likely contributes to suboptimal patient outcomes. To create sustainable, scalable, and widespread adherence to evidence-based guidelines, it is imperative to better understand individual surgeon motivations and behaviors associated with surgical decision-making. Objective To evaluate the systematic application of the Theoretical Domains Framework (TDF) to explore motivations and behaviors associated with surgical decision-making in abdominal wall hernia practice to help inform the future design of theory-based interventions for desired practice and behavior change. Design, Setting, and Participants This qualitative study used purposive sampling to recruit 21 practicing surgeons at community and academic hospitals from 5 health regions across Michigan. It used interviews consisting of clinical vignettes for highly controversial situations in abdominal wall hernia repair, followed by semistructured interview questions based on the domains of the TDF to gain nuance into motivating factors associated with surgical practice. Patterns within the data were located, analyzed, and identified through thematic analysis using software. All data were collected between May and July 2018, and data analysis was performed from August 2018 to July 2019. Main Outcomes and Measures Factors associated with decisions on the surgical approach to abdominal wall hernia repair were assessed using TDF. Results Seventeen (81%) of the 21 participants were men, with a median (interquartile range) age of 47 (45-54) years. Of the 14 TDF domains, 5 were found to be most associated with decisions on the surgical approach to abdominal wall hernia repair for surgeons in Michigan: knowledge, beliefs about consequences, social or professional role and identity, environmental context and resources, and social influences. Mapping of the findings to the sources of behavior identified the potential intervention functions and policy categories that could be targeted for intervention. The intervention functions found to be most relevant included education, persuasion, modeling, incentivization, and environmental restructuring. Conclusions and Relevance Using the TDF, this study found that the primary factors associated with individual practice were opinion leaders, practice conformity, and reputational concerns. These findings are important because they challenge traditional dogma, which relies mainly on dissemination of published evidence, education, and technical skills acquisition to achieve evidence-based practice. Such knowledge allows for the development of sustainable, theory-based interventions for adherence to evidence-based guidelines.

Randomized trials show that pneumatic dilation (PD) ≥30 mm and laparoscopic myotomy (LM) provide equivalent symptom relief and disease-related quality of life for patients with achalasia. However, questions remain about the safety, burden, and costs of treatment options.We performed a retrospective cohort study of achalasia patients initially treated with PD or LM (2009 to 2014) using the Truven Health MarketScan Research Databases. All patients had 1 year of follow-up after initial treatment. We compared safety, health care use, and total and out-of-pocket costs using generalized linear models.Among 1,061 patients, 82% were treated with LM. The LM patients were younger (median age 49 vs 52 years; p0.01), but were similar in terms of sex (p = 0.80) and prevalence of comorbid conditions (p = 0.11). There were no significant differences in the 1-year cumulative risk of esophageal perforation (LM 0.8% vs PD 1.6%; p = 0.32) or 30-day mortality (LM 0.3% vs PD 0.5%; p = 0.71). Laparoscopic myotomy was associated with an 82% lower rate of reintervention (p0.01), a 29% lower rate of subsequent diagnostic testing (p0.01), and a 53% lower rate of readmission (p0.01). Total and out-of-pocket costs were not significantly different (p0.05).In the US, LM appears to be the preferred treatment for achalasia. Both LM and PD appear to be safe interventions. Along a short time horizon, the costs of LM and PD were not different. Mirroring findings from randomized trials, LM is associated with fewer reinterventions, less diagnostic testing, and fewer hospitalizations.

Context: Lack of engagement with healthcare stakeholders results in missed opportunities to understand translation of evidence into practice.Case: Stakeholder engagement is a key component of the Comparing Outcomes of Drugs and Appendectomy (CODA) Study, a pragmatic clinical trial funded by PCORI to evaluate the effectiveness of antibiotics versus urgent appendectomy for acute uncomplicated appendicitis. We provide a framework for developing a stakeholder coordinating center (SCC) and describe two examples of how stakeholder engagement can inform study development.Findings: Coordinating engagement activities through the SCC established a commitment to the important partnership with stakeholders. It also facilitated communication and provided a central mechanism for obtaining input on key decisions such as development of patient-centered consent documents and appropriate stopping rules for a specific sub-population of patients with appendicitis.Major themes: Translatable lessons include thoughtful planning for engagement, identifying stakeholders with a direct interest in the study conduct and findings, and integration of input received into the decisions that drive the conduct of the study.Conclusions: Standards for conducting patient-centered research should address the ability to successfully engage patients by demonstrating the capacity to recruit study participants, engage them over the duration of the study, and disseminate findings that are congruent with stakeholder needs. The process of sharing important clinical research findings has improved patient care, and we believe that dissemination of novel engagement strategies can lead to increased success in study design and execution.

Background Prospect theory suggests that when faced with an uncertain outcome, people display loss aversion by preferring to risk a greater loss rather than incurring certain, lesser cost. Providing probability information improves decision making towards the economically optimal choice in these situations. Clinicians frequently make decisions when the outcome is uncertain, and loss aversion may influence choices. This study explores the extent to which prospect theory, loss aversion, and probability information in a non-clinical domain explains clinical decision making under uncertainty. Methods Four hundred sixty two participants (n = 117 non-medical undergraduates, n = 113 medical students, n = 117 resident trainees, and n = 115 medical/surgical faculty) completed a three-part online task. First, participants completed an iced-road salting task using temperature forecasts with or without explicit probability information. Second, participants chose between less or more risk-averse (“defensive medicine”) decisions in standardized scenarios. Last, participants chose between recommending therapy with certain outcomes or risking additional years gained or lost. Results In the road salting task, the mean expected value for decisions made by clinicians was better than for non-clinicians(−$1,022 vs -$1,061

Background Randomized trials have found that alvimopan hastens return of bowel function and reduces length of stay (LOS) by 1 day among patients undergoing colorectal surgery. However, its effectiveness in routine clinical practice and its impact on hospital costs remain uncertain. Study Design We performed a retrospective cohort study of patients undergoing elective colorectal surgery in Washington state (2009 to 2013) using data from a clinical registry (Surgical Care and Outcomes Assessment Program) linked to a statewide hospital discharge database (Comprehensive Hospital Abstract Reporting System). We used generalized estimating equations to evaluate the relationship between alvimopan and outcomes, and adjusted for patient, operative, and management characteristics. Hospital charges were converted to costs using hospital-specific charge to cost ratios, and were adjusted for inflation to 2013 US dollars. Results Among 14,781 patients undergoing elective colorectal surgery at 51 hospitals, 1,615 (11%) received alvimopan. Patients who received alvimopan had a LOS that was 1.8 days shorter (p Conclusions When used in routine clinical practice, alvimopan was associated with a shorter LOS and limited but significant hospital cost savings. Both efficacy and effectiveness data support the use of alvimopan in routine clinical practice, and its use could be measured as a marker of higher quality care.