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The aims of this study were (1) to evaluate the feasibility of using the Non-Technical Skills for Surgeons (NOTSS) rating tool in assessing surgeons' non-technical skills behaviors in live operations, and (2) to describe the effect of NOTSS on intraoperative performance.This study was conducted in an academic hospital in North America. Two observers independently conducted direct non-participant observations using the NOTSS rating tool to assess non-technical skills, and to document examples of effective or ineffective non-technical skills behaviors. Observers took field notes to document non-technical skill gaps that were not captured by the NOTSS rating tool, and situations or scenarios that presented challenges for accurate assessment. Interclass correlation estimates and 95% confidence intervals were calculated to assess the validity of the NOTSS rating tool. Deductive thematic qualitative data analysis was used for field notes and NOTSS behavior descriptions.Participants were general surgeons performing either minimally invasive (robotic assisted or laparoscopic surgery), or open procedures.We observed 18 surgeries, involving 6 surgeons, 11 residents and one fellow resulting in 37 hours of direct observations. The mean NOTSS score was 3.8 (SD 0.41) for situation awareness, 3.75 (SD 0.47) for decision-making, 3.71 (SD 0.39) for communication and teamwork, and 3.76 (SD 0.38) for leadership. The inter-rater reliability ranged between 0.65 and 0.80 for each NOTSS categories. The observers documented examples of effective non-technical skills behaviors and examples of behaviors that need improvement. Furthermore, we described the effect of each observed behavior on intraoperative performance. One challenge to NOTSS use in live surgery was that observers had to infer situation awareness, decision-making, and coping with pressure as these were not easily observed without attending surgeons articulating their underlying thought process.The use of the NOTSS tool in live surgery is a valid and practical tool to document observed behaviors and their effect on intraoperative performance in order to provide constructive feedback to surgeons. One notable limitation is that without specific articulation by the surgeon of their underlying thought process the observer must infer specific elements. By documenting specific real-world events with high inter-rater reliability and adequate surgeon score variation the process can be used to provide useful feedback for improvement.

Purpose We examined the prevalence of, and factors associated with, serious opioid-related adverse drug events (ORADEs) that led to an emergency department (ED) visit or hospitalization among patients with chronic gastrointestinal (GI) symptoms and disorders dually enrolled in the Department of Veterans Affairs (VA) and Medicare Part D. Methods In this retrospective cohort study, we used linked national patient-level data (April 1, 2011, to October 31, 2014) from the VA and Centers for Medicare and Medicaid Services to identify serious ORADEs among dually enrolled veterans with a chronic GI symptom or disorder. Outcome measures included serious ORADEs, defined as an ED visit attributed to an ORADE or a hospitalization where the principal or secondary reason for admission involved an opioid. We used multiple logistic regression models to determine factors independently associated with a serious ORADE. Results We identified 3,430 veterans who had a chronic GI symptom or disorder; were dually enrolled in the VA and Medicare Part D; and had a serious ORADE that led to an ED visit, hospitalization, or both. The period prevalence of having a serious ORADE was 2.4% overall and 4.4% among veterans with chronic opioid use (≥90 consecutive days). Veterans with serious ORADEs were more likely to be less than 40 years old, male, white, and to have chronic abdominal pain, functional GI disorders, chronic pancreatitis, or Crohn’s disease. They were also more likely to have used opioids chronically and at higher daily doses. Conclusion There may be a considerable burden of serious ORADEs among patients with chronic GI symptoms and disorders. Future quality improvement efforts should target this vulnerable population.

Introduction Gastrointestinal (GI) symptoms and disorders affect an increasingly large group of veterans. Opioid use may be rising in this population, but this is concerning from a patient safety perspective, given the risk of dependence and lack of evidence supporting opioid use to manage chronic pain. We examined the characteristics of opioid prescriptions and factors associated with chronic opioid use among chronic GI patients dually enrolled in the DVA and Medicare Part D. Materials and Methods In this retrospective cohort study, we used linked, national patient-level data (from April 1, 2011, to December 31, 2014) from the VA and Centers for Medicare & Medicaid Services to identify chronic GI patients and observe opioid use. Veterans who had a chronic GI symptom or disorder were dually enrolled in VA and Part D and received ≥1 opioid prescription dispensed through the VA, Part D, or both. Chronic GI symptoms and disorders included chronic abdominal pain, chronic pancreatitis, inflammatory bowel diseases, and functional GI disorders. Key outcome measures were outpatient opioid prescription dispensing overall and chronic opioid use, defined as ≥90 consecutive days of opioid receipt over 12 months. We described patient characteristics and opioid use measures using descriptive statistics. Using multiple logistic regression modeling, we generated adjusted odds ratios and 95% CIs to determine variables independently associated with chronic opioid use. The final model included variables outlined in the literature and our conceptual framework. Results We identified 141,805 veterans who had a chronic GI symptom or disorder, were dually enrolled in VA and Part D, and received ≥1 opioid prescription dispensed from the VA, Part D, or both. Twenty-six percent received opioids from the VA only, 69% received opioids from Medicare Part D only, and 5% were “dual users,” receiving opioids through both VA and Part D. Compared to veterans who received opioids from the VA or Part D only, dual users had a greater likelihood of potentially unsafe opioid use outcomes, including greater number of days on opioids, higher daily doses, and higher odds of chronic use. Conclusions Chronic GI patients in the VA may be frequent users of opioids and may have a unique set of risk factors for unsafe opioid use. Careful monitoring of opioid use among chronic GI patients may help to begin risk stratifying this group. and develop tailored approaches to minimize chronic use. The findings underscore potential nuances within the opioid epidemic and suggest that components of the VA’s Opioid Safety Initiative may need to be adapted around veterans at a higher risk of opioid-related adverse events.

Background: In the U.S., 50–75% of nonmedical users of prescription opioids obtain their pills through diversion by friends or relatives. Increasing disposal of unused opioid prescriptions is a fundamental primary prevention strategy in combatting the opioid epidemic. Objectives: To identify interventions for disposal of unused opioid pills and assess the evidence of their effectiveness on disposal-related outcomes. Methods: A search of four electronic databases was conducted (October 2019). We included all empirical studies, systematic literature reviews, and meta-analyses about study medication disposal interventions in the U.S. Studies of disposal interventions that did not include opioids were excluded. We abstracted data for the selected articles to describe the study design, and outcomes. Further, we assessed the quality of each study using the NIH Study Quality Assessment Tools. Results: We identified 25 articles that met our inclusion criteria. None of the 13 studies on drug take-back events or the two studies on donation boxes could draw conclusions about their effectiveness. Although studies on educational interventions found positive effects on knowledge acquisition, they did not find differences in disposal rates. Two randomized controlled trials on drug disposal bags found higher opioid disposal rates in their intervention arms compared to the control arms (57.1% vs 28.6% and 33.3%, p = .01; and 85.7% vs 64.9%, p = .03). Conclusions: Peer-reviewed publications on opioid disposal interventions are limited and either do not address effectiveness or have conflicting findings. Future research should address these limitations and further evaluate implementation and cost-effectiveness.

Background In this study, we developed online interactive clinician education modules highlighting best practices to minimize opioid prescribing at discharge after surgery. The modules were implemented as part of a multicomponent quality improvement initiative across a six-hospital health system. This article describes the development and evaluation of this educational intervention. Materials and Methods Clinician education modules targeting surgical prescribers, nurses, and pharmacists were developed and implemented by an interdisciplinary team. Clinicians were invited to participate in an evaluation survey after completing the modules. Survey items assessed clinicians’ rating of the module and intention to change clinical practice because of the module. Quantitative and qualitative survey responses were analyzed by the study team. Results A total of 2119 clinicians completed the module and 1831 of these clinicians (86.4%) completed the survey. Of clinicians completing the survey, 65.6% reported that they intend to change clinical practice after completing the module. Intended changes were related to increased knowledge and awareness, provider empowerment, opioid prescribing practices, nonopioid prescribing practices, and patient education. Many clinicians who indicated they do not intend to change practice reported that their clinical practices were already in line with module recommendations. Some clinicians did not perceive the module to be relevant to their role. Conclusions Module completion was associated with the intention to improve clinical practice in areas related to provider empowerment, opioid prescribing, nonopioid prescribing, and patient education. Evaluation data will inform future module improvements. There is an opportunity to ensure that all clinicians, including those who are not prescribers, recognize their role in opioid stewardship.

Greater than 25% of all men develop an inguinal hernia in their lifetime, and more than 20 million inguinal hernia repair surgeries are performed worldwide each year. The mechanisms causing abdominal muscle weakness, the formation of inguinal hernias, or their recurrence are largely unknown. We previously reported that excessively produced estrogen in the lower abdominal muscles (LAMs) triggers extensive LAM fibrosis, leading to hernia formation in a transgenic male mouse model expressing the human aromatase gene (Aromhum). To understand the cellular basis of estrogen-driven muscle fibrosis, we performed single-cell RNA sequencing on LAM tissue from Aromhum and wild-type littermates. We found a fibroblast-like cell group composed of 6 clusters, 2 of which were validated for their enrichment in Aromhum LAM tissue. One of the potentially novel hernia-associated fibroblast clusters in Aromhum was enriched for the estrogen receptor-α gene (Esr1hi). Esr1hi fibroblasts maximally expressed estrogen target genes and seemed to serve as the progenitors of another cluster expressing ECM-altering enzymes (Mmp3hi) and to upregulate expression of proinflammatory, profibrotic genes. The discovery of these 2 potentially novel and unique hernia-associated fibroblasts may lead to the development of novel treatments that can nonsurgically prevent or reverse inguinal hernias.

To assess the reliability of peer-review of TURBT videos as a means to evaluate surgeon skill and its relationship to detrusor sampling.Urologists from an academic health system submitted TURBT videos in 2019. Ten blinded peers evaluated each surgeon's performance using a 10-item scoring instrument to quantify surgeon skill. Normalized composite skill scores for each surgeon were calculated using peer ratings. For surgeons submitting videos, we retrospectively reviewed all TURBT pathology results (2018-2019) to assess surgeon-specific detrusor sampling. A hierarchical logistic regression model was fit to evaluate the association between skill and detrusor sampling, adjusting for patient and surgeon factors.Surgeon skill scores and detrusor sampling rates were determined for 13 surgeons performing 245 TURBTs. Skill scores varied from -6.0 to 5.1 [mean: 0; standard deviation (SD): 2.40]. Muscle was sampled in 72% of cases, varying considerably across surgeons (mean: 64.5%; SD: 30.7%). Among 8 surgeons performing5 TURBTs during the study period, adjusted detrusor sampling rate was associated with sending separate deep specimens (odds ratio [OR]: 1.97; 95% confidence interval [CI]: 1.02-3.81, P = .045) but not skill (OR: 0.81; 95% CI: 0.57-1.17, P = .191).Surgeon skill was not associated with detrusor sampling, suggesting there may be other drivers of variability of detrusor sampling in TURBT.

Background The United States is in the midst of an opioid epidemic. In response, our institution developed the Minimizing Opioid Prescribing in Surgery (MOPiS) initiative. MOPiS is a multicomponent intervention including: (1) patient education on opioid safety and pain management expectations; (2) clinician education on safe opioid prescribing; (3) prescribing data feedback; (4) patient risk screening to assess for addictive behavior; and (5) optimizations to the electronic health record (EHR). We conducted a preintervention formative evaluation to identify barriers and facilitators to implementation. Materials and methods We conducted 22 semistructured interviews with key stakeholders (surgeons, nurses, pharmacists, and administrators) at six hospitals within a single health care system. Interviewees were asked about perceived barriers and facilitators to the components of the intervention. Responses were analyzed to identify common themes using the Consolidated Framework for Implementation Research. Results We identified common themes of potential implementation barriers and classified them under 12 Consolidated Framework for Implementation Research domains and three intervention domains. Time and resource constraints (needs and resources), the modality of educational material (design quality and packaging), and prescribers’ concern for patient satisfaction scores (external policy and incentives) were identified as the most significant structural barriers. Resident physicians, pharmacists, and pain specialists were identified as potential key facilitating actors to the intervention. Conclusions We identified specific barriers to successful implementation of an opioid reduction initiative in a surgical setting. In our MOPiS initiative, a preintervention formative evaluation enabled the design of strategies that will overcome implementation barriers specific to the components of our initiative.

Healthcare consumers seeking accurate information about where to find quality surgical care face a confusing constellation of rating systems that lack transparency or consistency of opinion. For example, a 2016 report in Health Affairs demonstrated that no hospital was rated as a high performer by all four prominent national ratings systems: Consumer Reports, Leapfrog, Healthgrades and U.S. News & World Report (Austin et al. Health Aff 34:423–430, 2015). Surgeons should have an understanding of the current state of public reporting of quality; hospital ratings and data sources; physician ratings and data sources; and transparency of reporting. We conducted a non-systematic review of the literature. Hospital quality ratings remain nebulous and there is not universal opinion on the utility of voluntary participation in ranking systems, leaving the current systems largely opinion-based. Early attempts at physician ranking systems are rudimentary at best and suffer from methodological concerns. Publicly reported metrics should be easily understandable, accessible, clinically relevant, reliable, non-punitive, and shielded from legal discovery. Transparency is increasing within institutions to help align staff to institutional objectives, while specialty specific registries are helping to standardize care pathways and outcomes measures across organizations. Measuring surgical outcomes beyond 30-day morbidity and mortality has been plagued by a lack of understanding on how to create metrics that matter; the four attributes of relevance, scientific soundness, feasibility and comprehensiveness set a high bar for the development of effective and efficient quality measures in surgery. SAGES, via the Quality, Outcomes, and Safety Committee, is committed to learning how to develop meaningful quality metrics in general surgery and will continue to work in other areas that impact quality, such as opioid prescribing, and surgeon wellness.

BACKGROUND: We evaluated the effects of surgeon characteristics such as surgeon experience on differences in opioid prescribing after surgery. METHODS: We evaluated a 20% national sample of Medicare beneficiaries ≥65 years old who underwent 15 different types of surgery to identify surgeon characteristics associated with opioid prescription size filled within seven days of discharge using a multi-level linear model. RESULTS: 174,141 patients and 13,828 surgeons met inclusion criteria. 53.8% of patients filled an opioid prescription within seven days postoperatively. The amount of opioids prescribed after surgery was highest for patients whose surgeons were early in practice (i.e. 0–7 years in practice). Surgeon credentials, type of surgery, and geographic region were associated with differing sizes of opioid fills postoperatively. CONCLUSIONS: Surgeon characteristics such as cumulative years of practice contribute to differences in prescribing behavior after surgery. These findings can help develop strategic interventions to enhance opioid stewardship.

Background Few opportunities exist for surgeons to receive technical skills feedback after training. Surgeons at hospitals within the Illinois Surgical Quality Improvement Collaborative were invited to participate in a peer-to-peer video-based coaching initiative focused on improving technical skills in laparoscopic right colectomy. We present a formative qualitative evaluation of a video-based coaching initiative. Methods Concurrent with the implementation of our video-based coaching initiative, we conducted two focus groups and 15 individual semistructured interviews with participants; all interviews were audio-recorded and transcribed. A subset of surgeons participated in a group video-review session, which was observed by qualitative researchers. Transcripts and notes were analyzed using an organizational behavior framework adapted from executive coaching. Results Participation in the initiative was primarily motivated by the opportunity to learn from others and improve skills. Surgeons highlighted the value of self-video and peer-video assessment not only to learn new techniques but also for self-reflection and benchmarking. Barriers to participation included logistics (e.g. using the laparoscopic recording devices, coordinating schedules for peer coaching), time commitment, and a surgical culture that assumes the intent of coaching is to address deficiencies. Conclusions Video-based peer-coaching provides a platform for surgeons to reflect, benchmark against peers, and receive personalized feedback; however, more work is needed to increase participation and sustain involvement over time. There is an opportunity to decrease logistical barriers and increase acceptability of coaching by integrating video-based coaching into existing surgical conferences and established continuous professional development efforts.

BACKGROUND. In a cohort of Veterans dually enrolled in the Department of Veterans Affairs (VA) and Medicare Part D, we sought to describe high-dose daily opioid use among Veterans with unexplained gastrointestinal (GI) symptoms & structural GI diagnoses and examine factors associated with high-dose use. METHODS. We used linked national patient-level data from the VA and Centers for Medicare & Medicaid Services (CMS). We grouped patients into 3 subsets: those with unexplained GI symptoms (e.g. chronic abdominal pain); structural GI diagnoses (e.g. chronic pancreatitis); and those with a concurrent unexplained GI symptom & structural GI diagnosis. High-dose daily opioid use levels were examined as a binary variable (≥100 morphine milligram equivalents (MME)/day) and as an ordinal variable (50-99 MME/day, 100-119 MME/day, or ≥120 MME/day). RESULTS. We identified 141,805 chronic GI patients dually enrolled in VA & Part D. High-dose opioid use was present in 11% of Veterans with unexplained GI symptoms, 10% of Veterans with structural GI diagnoses, and 15% of Veterans in the concurrent GI group. Compared to Veterans with only an unexplained GI symptom or structural diagnosis, concurrent GI patients were more likely to have higher daily opioid doses, more opioid days ≥100 MME, and higher risk of chronic use. Factors associated with high-dose use included opioid receipt from both VA & Part D, younger age, and benzodiazepine use. CONCLUSIONS. A significant subset of chronic GI patients in the VA are high-dose opioid users. Efforts are needed to reduce high-dose use among Veterans with concurrent GI symptoms and diagnoses.

IMPORTANCE: Resident operative autonomy has been steadily decreasing. Whether this reduction in autonomy has been associated with changes in patient outcomes is unclear. OBJECTIVE: To assess whether surgical procedures performed by residents without an attending surgeon scrubbed are associated with differences in patient outcomes compared with procedures performed by attending surgeons alone or by residents with the assistance of attending surgeons. DESIGN, SETTING, AND PARTICIPANTS: This retrospective propensity score–matched cohort study analyzed 30-day outcomes among patients who received operations at US Veterans Affairs (VA) medical centers and were recorded within the VA Surgical Quality Improvement Program (VASQIP) database from July 1, 2004, to September 30, 2019. Among 1 797 056 operations recorded in the VASQIP during that period, 1 319 020 were eligible for inclusion. Operations performed by a surgical resident without an attending surgeon scrubbed (resident primary) were propensity score matched on a 1:1 ratio (based on year of procedure and patient age, race, sex, American Society of Anesthesiologists physical status classification, functional status, emergency status, inpatient status, presence of multiple comorbidities, and Current Procedural Terminology code) to operations performed by an attending surgeon only (surgeon primary) and operations performed by a resident with assistance from an attending surgeon (resident plus surgeon). EXPOSURES: Level of resident involvement. MAIN OUTCOMES AND MEASURES: Thirty-day adjusted all-cause mortality. RESULTS: Among 1 319 020 surgical procedures included, 138 750 were performed by residents only, 308 724 were performed by surgeons only, and 871 546 were performed by residents and surgeons. For the 1 319 020 total cases, patients’ mean (SD) age was 61.6 (12.9) years; 1 223 051 patients (92.7%) were male; and 212 315 (16.1%) were Black or African American, 63 817 (4.9%) were Hispanic, 830 704 (63.0%) were White, and 212 814 (16.1%) were of other or unknown race and ethnicity. Propensity score matching produced 101 130 pairs of resident-primary and surgeon-primary procedures and 137 749 pairs of resident-primary and resident plus surgeon procedures. Patient all-cause mortality and morbidity were no different among those who received surgeon-primary procedures (mortality: odds ratio [OR], 1.03 [95% CI, 0.95-1.12]; morbidity: OR, 1.01 [95% CI, 0.97-1.05]) vs resident plus surgeon procedures (mortality: OR, 1.03 [95% CI, 0.97-1.11]; all-cause morbidity: OR, 0.97 [95% CI, 0.95-1.00]). Resident-primary procedures had longer operative times than surgeon-primary procedures (median, 80 minutes [IQR, 50-123 minutes] vs 70 minutes [IQR, 41-114 minutes], respectively; P

Background Adverse postoperative outcomes related to smoking are well established, yet current smokers continue to be offered elective surgery in the US. It is unknown whether patients undergoing low-risk, elective procedures, who actively smoke experience increased risk of complications. We sought to determine the increased burden of complications following elective hernia repair procedures in patients identified as current smokers. Methods We identified patients undergoing elective incisional, inguinal, umbilical, or ventral hernia repair from 2011 to 2014 using the American College of Surgeons National Surgical Quality Improvement Project (ACS NSQIP) database. Multivariable logistic regression analysis was used to examine the association between current smoking and 30-day postoperative outcomes, adjusting for demographics and comorbidities. Results Of 220,629 patients who underwent elective hernia repair, 40,446 (18.3%) self-identified as current smokers within the past 12 months. Current smokers experienced an increased likelihood (Odds Ratio [95% Confidence interval]) of reoperation (OR 1.23 [95% CI 1.11–1.36]), readmission (OR 1.24 [95% CI 1.16–1.32]), and death (OR 1.53 [95% CI 1.06–2.22]). Furthermore, smokers experienced an increased risk of postoperative pulmonary, infectious, and wound complications, but there was no increased risk of requiring transfusion or of postoperative cardiac or thromboembolic events. Conclusions Current smokers were more likely to experience serious postoperative complications within 30 days. Given the volume of elective hernia surgery performed in the US, encouraging smoking cessation prior to offering elective repair could reduce postoperative complications, reoperation, readmission, and mortality.

BACKGROUND: Surgeons play a pivotal role in the opioid epidemic but it is unknown how different members of a surgical team vary in the way they prescribe opioids after surgical episodes. STUDY DESIGN: We conducted a retrospective cohort study of all inpatient discharges for 5 common surgeries. Total number of tablets and total milligram equivalents (MME) prescribed were calculated and differences in prescription patterns were determined for attending surgeons, surgical residents and advanced practice providers. Using a generalized ordered logistic regression, we examined factors associated with ordering a higher number of tablets or MME. RESULTS: The median number of tablets (range) prescribed by rank were attending surgeon 30 (6–72), surgical resident 20 (6–189) and advanced care practitioner 40 (5–1000); p

Exposure to pain management curriculum in medical school is currently variable. This paper reports on formal prescribing education, self-perceived prescribing readiness, and prescribing practices among incoming surgical residents before and after a pain management training session.Pre-residency survey of thirty surgical interns at a single urban medical center, followed by a repeat survey after an educational session on prescription writing and opioid abuse.Thirty-three percent of respondents had formal education on prescription writing in medical school. Median subjective preparedness to write an opioid prescription was 1.5 (range 1-10) on a 1-10 Likert scale. Ranges of morphine milligram equivalents (MME) prescribed varied from 420-2700 MME for 8 mock surgical scenarios. Post-training, median subjective preparedness increased to 3.5 (range 1-6) and prescription accuracy (the inclusion of a medication, dose, frequency, and duration) improved from 75% to 97% (p 0.001). Overall, 90% of interns found the training session useful.Most surgical interns were not trained in prescribing narcotics in medical school. Improved pain management curriculum is necessary to assure safe and consistent opioid prescriptions.

Objective/Study Question To estimate and compare sample average treatment effects (SATE) and population average treatment effects (PATE) of a resident duty hour policy change on patient and resident outcomes using data from the Flexibility in Duty Hour Requirements for Surgical Trainees Trial (“FIRST Trial”). Data Sources/Study Setting Secondary data from the National Surgical Quality Improvement Program and the FIRST Trial (2014–2015). Study Design The FIRST Trial was a cluster-randomized pragmatic noninferiority trial designed to evaluate the effects of a resident work hour policy change to permit greater flexibility in scheduling on patient and resident outcomes. We estimated hierarchical logistic regression models to estimate the SATE of a policy change on outcomes within an intent-to-treat framework. Propensity score-based poststratification was used to estimate PATE. Data Collection/Extraction Methods This study was a secondary analysis of previously collected data. Principal Findings Although SATE estimates suggested noninferiority of outcomes under flexible duty hour policy versus standard policy, the noninferiority of a policy change was inconclusively noninferior based on PATE estimates due to imprecision. Conclusions Propensity score-based poststratification can be valuable tools to address trial generalizability but may yield imprecise estimates of PATE when sparse strata exist.

Background Because many patients are first exposed to opioids after general surgery procedures, surgical stewardship for the use of opioids is critical in addressing the opioid crisis. We developed a multi-component opioid reduction program to minimize the use of opioids after surgery. Our objectives were to assess patient exposure to the intervention and to investigate the association with postoperative use and disposal of opioids. Methods We implemented a multi-component intervention, including patient education, the settings of expectations, the education of the providers, and an in-clinic disposal box in our large, academic, general surgery clinic. From April to December 2018, patients were surveyed by phone 30 to 60 days after their operation regarding their experience with postoperative pain management. The association between patient education and preparedness to manage pain was assessed using χ2 tests. Education, preparedness, and clinical factors were evaluated for association with quantity of pills used using ANOVA and multivariable linear regression. Results Of the 389 eligible patients, 112 responded to the survey (28.8%). Patients receiving both pre and postoperative education were more likely to feel prepared to manage pain than those who only received the education pre or postoperatively (91% vs 68%, P = .01). Patients who felt prepared to manage their pain used 9.1 fewer pills on average than those who did not (P = .01). Fourteen patients (24%) with excess pills disposed of them. Preoperative education was associated with disposal of excess pills (30% vs 0%, P Conclusion Exposure to clinic-based interventions, particularly preoperatively, can increase patient preparedness to manage postoperative pain and decrease the quantity of opioids used. Additional strategies are needed to increase appropriate disposal of unused opioids.

OBJECTIVES The ProPublica Surgeon Scorecard is the first nationwide, multispecialty public reporting of individual surgeon outcomes. However, ProPublica's use of a previously undescribed outcome measure (composite of in-hospital mortality or 30-day related readmission) and inclusion of only inpatients have been questioned. Our objectives were to (1) determine the proportion of cases excluded by ProPublica's specifications, (2) assess the proportion of inpatient complications excluded from ProPublica's measure, and (3) examine the validity of ProPublica's outcome measure by comparing performance on the measure to well-established postoperative outcome measures. METHODS Using ACS-NSQIP data (2012-2014) for 8 ProPublica procedures and for All Operations, the proportion of cases meeting all ProPublica inclusion criteria was determined. We assessed the proportion of complications occurring inpatient, and thus not considered by ProPublica's measure. Finally, we compared risk-adjusted performance based on ProPublica's measure specifications to established ACS-NSQIP outcome measure performance (eg, death/serious morbidity, mortality). RESULTS ProPublica's inclusion criteria resulted in elimination of 82% of all operations from assessment (range: 42% for total knee arthroplasty to 96% for laparoscopic cholecystectomy). For all ProPublica operations combined, 84% of complications occur during inpatient hospitalization (range: 61% for TURP to 88% for total hip arthroplasty), and are thus missed by the ProPublica measure. Hospital-level performance on the ProPublica measure correlated weakly with established complication measures, but correlated strongly with readmission (R = 0.834, P < 0.001). CONCLUSIONS ProPublica's outcome measure specifications exclude 82% of cases, miss 84% of postoperative complications, and correlate poorly with well-established postoperative outcomes. Thus, the validity of the ProPublica Surgeon Scorecard is questionable.

This cohort study examines the association between surgical technical skill and overall survival following colectomy for colon cancer.

IMPORTANCE: Postoperative complications remain common after surgery, but little is known about the extent of variation in operative technical skill and whether variation is associated with patient outcomes. OBJECTIVES: To examine the (1) variation in technical skill scores of practicing surgeons, (2) association between technical skills and patient outcomes, and (3) amount of variation in patient outcomes explained by a surgeon’s technical skill. DESIGN, SETTING, AND PARTICIPANTS: In this quality improvement study, 17 practicing surgeons submitted a video of a laparoscopic right hemicolectomy that was then rated by at least 10 blinded peer surgeons and 2 expert raters. The association between surgeon technical skill scores and risk-adjusted outcomes was examined using data from the American College of Surgeons National Surgical Quality Improvement Program. The association between technical skill scores and outcomes was examined for colorectal procedures and noncolorectal procedures (ie, assessed on whether technical skills demonstrated during colectomy were associated with patient outcomes across other cases). In addition, the proportion of patient outcomes explained by technical skill scores was examined using robust regression techniques. The study was conducted from September 23, 2016, to February 10, 2018; data analysis was performed from November 2018 to January 2019. EXPOSURES: Colorectal and noncolorectal procedures. MAIN OUTCOMES AND MEASURES: Any complication, mortality, unplanned hospital readmission, unplanned reoperation related to principal procedure, surgical site infection, and death or serious morbidity. RESULTS: Of the 17 surgeons included in the study, 13 were men (76%). The participants had a range from 1 to 28 years in surgical practice (median, 11 years). Based on 10 or more reviewers per video and with a maximum quality score of 5, overall technical skill scores ranged from 2.8 to 4.6. From 2014 to 2016, study participants performed a total of 3063 procedures (1120 colectomies). Higher technical skill scores were significantly associated with lower rates of any complication (15.5% vs 20.6%, P = .03; Spearman rank-order correlation coefficient r = −0.54, P = .03), unplanned reoperation (4.7% vs 7.2%, P = .02; r = −0.60, P = .01), and a composite measure of death or serious morbidity (15.9% vs 21.4%, P = .02; r = −0.60, P = .01) following colectomy. Similar associations were found between colectomy technical skill scores and patient outcomes for all types of procedures performed by a surgeon. Overall, technical skill scores appeared to account for 25.8% of the variation in postcolectomy complication rates and 27.5% of the variation when including noncolectomy complication rates. CONCLUSIONS AND RELEVANCE: The findings of this study suggest that there is wide variation in technical skill among practicing surgeons, accounting for more than 25% of the variation in patient outcomes. Higher colectomy technical skill scores appear to be associated with lower complication rates for colectomy and for all other procedures performed by a surgeon. Efforts to improve surgeon technical skills may result in better patient outcomes.

Background The “safety culture” within hospital systems is increasingly recognized as important to delivery of high-quality care. We examine the safety culture in a statewide hospital quality improvement collaborative and its associations with surgical outcomes. Study Design A modified Safety Attitudes Questionnaire was sent to administrators, quality improvement teams, nurses, anesthesiologists, and surgeons in 49 hospitals participating in the Illinois Surgical Quality Improvement Collaborative in 2015. Associations between positive safety culture, as measured by percentage of positive responses on the Safety Attitudes Questionnaire, and the following NSQIP 30-day adverse outcomes: hospital-level risk-adjusted morbidity, mortality, death, or serious morbidity and readmission rates. Linear regression models with hospitals clustered by system were used to assess the relationship between safety culture and patient outcomes. Results Operating room safety culture scores were highest (97.7% positive) compared with the other domains, and ratings of hospital management were lowest (75.9% positive). Hospital administrators consistently had the most positive perception of the safety culture (90.5% positive) and front-line providers were less positive: physicians (85.3%), advanced practice providers (88.1%), and nurses (80%). Teamwork was rated as a strength by patient care providers (physicians 88.3%, advanced practice providers 90.2%, and nurses 82.2%), but was perceived as weakest by administrators. Higher percentage of positive Safety Attitudes Questionnaire responses was significantly associated with lower risk of postoperative morbidity (p = 0.007) and death or serious morbidity (p = 0.04). No significant association between safety culture and the risk of mortality (p = 0.23) or readmissions (p = 0.52) was observed. Conclusions Hospital safety culture can influence certain surgical patient outcomes. Improving the safety culture within a hospital can represent a previously unrecognized approach that can be leveraged to strengthen surgical quality improvement efforts at the hospital level.

Background Surgeon performance profiling is of great interest to surgeons, hospitals, health plans, and the public, yet efforts to date have been contested, with stakeholders at odds over the selection, reliability, and validity of metrics used. We sought to create surgeon-level comparative assessments within the Illinois Surgical Quality Improvement Collaborative. Study Design American College of Surgeons NSQIP data were obtained for 51 Illinois hospitals covering a 30-month period from 2014 to 2016. Surgeon-level, risk-adjusted outcomes rates were estimated from 3-level crossed random effects logistic regression models and classified as low, as expected, or high for each of 7 postoperative outcomes. Model intra-class correlations and provider-specific reliability statistics were calculated. Results A total of 123,141 cases were analyzed for 2,724 surgeons. Median provider case volume was 17 (interquartile range 4 to 54). Overall crude complication rates ranged from 0.62% to 7.14% across the 7 outcomes investigated. Surgeon-level variance estimates were low (intra-class correlation coefficients between 0.007 and 0.074). No performance outliers were detected for 3 of the outcomes measures, while a small number of outliers were identified for any morbidity (11 surgeons), surgical site infection (10 surgeons), death or serious morbidity (8 surgeons), and reoperation (1 surgeon). Among all physicians, median reliability was below 0.1 for each outcome. Conclusions Few individual surgeon performance outliers could be detected in NSQIP clinical registry data for a statewide hospital collaborative over a 30-month period using postoperative patient outcomes. Low surgeon-specific case volumes and minimal variance between surgeons may limit the utility of American College of Surgeons NSQIP outcomes measures for individual profiling. Alternative metrics, such as process measures, patient experience, composite measures, or technical skill assessments should be explored for surgeon-level measurement.

Unexpected variations in postoperative length of stay (LOS) negatively impact resources and patient outcomes. Statistical process control (SPC) measures performance, evaluates productivity, and modifies processes for optimal performance. The goal of this study was to initiate SPC to identify LOS outliers and evaluate its feasibility to improve outcomes in colorectal surgery.Review of a prospective database identified colorectal procedures performed by a single surgeon. Patients were grouped into elective and emergent categories and then stratified by laparoscopic and open approaches. All followed a standardized enhanced recovery protocol. SPC was applied to identify outliers and evaluate causes within each group.A total of 1294 cases were analyzed--83% elective (n = 1074) and 17% emergent (n = 220). Emergent cases were 70.5% open and 29.5% laparoscopic; elective cases were 36.8% open and 63.2% laparoscopic. All groups had a wide range in LOS. LOS outliers ranged from 8.6% (elective laparoscopic) to 10.8% (emergent laparoscopic). Evaluation of outliers demonstrated patient characteristics of higher ASA scores, longer operating times, ICU requirement, and temporary nursing at discharge. Outliers had higher postoperative complication rates in elective open (57.1 vs. 20.0%) and elective lap groups (77.6 vs. 26.1%). Outliers also had higher readmission rates for emergent open (11.4 vs. 5.4%), emergent lap (14.3 vs. 9.2%), and elective lap (32.8 vs. 6.9%). Elective open outliers did not follow trends of longer LOS or higher reoperation rates.SPC is feasible and promising for improving colorectal surgery outcomes. SPC identified patient and process characteristics associated with increased LOS. SPC may allow real-time outlier identification, during quality improvement efforts, and reevaluation of outcomes after introducing process change. SPC has clinical implications for improving patient outcomes and resource utilization.

Background We sought to evaluate the results of a new mesh sutured repair technique for closure of contaminated incisional hernias. Methods 48 patients with contaminated hernias 5 cm wide or greater by CT scan were closed with mesh sutures. Surgical site occurrence, infections, and hernia recurrence were compared to similar patient series reported in the literature. Results Of the 48 patients, 20 had clean-contaminated wounds, 16 had contaminated wounds, and 12 were infected. 69% of the patients underwent an anterior perforator sparing components release for hernias that averaged 10.5 cm transversely (range 5 cm–25 cm). SSO occurred in 27% of patients while SSI was 19%. There were no fistulas or delayed suture sinuses. With a mean follow-up of almost 12 months, 3 midline hernias recurred (6%). In these same patients, three parastomal hernias repaired with mesh sutures failed out of 4 attempted for a total failure rate of 13%. Conclusion Mesh sutured closure represents a simplified and effective surgical strategy for contaminated midline incisional hernia repair.

Prophylactic central compartment neck dissection (pCCND) is a CCND in patients with thyroid cancer who have no clinical, sonographic, or intraoperative evidence of abnormal lymph nodes. Whether pCCND should be performed in all patients with clinically node-negative papillary thyroid cancer (PTC) is controversial. Existing data reveal that for patients with clinically node-negative PTC there is no difference between treatment with total thyroidectomy plus pCCND and total thyroidectomy alone. The potential increased risk of hypoparathyroidism associated with CCND is not offset by any measurable oncologic benefit. Risk/benefit balance favors total thyroidectomy alone for patients with clinically node-negative PTC.

BACKGROUND After more than a decade of improvement, our enhanced recovery pathway had patients who had undergone laparoscopic colectomy going home a mean 3.7 days postoperatively. We wondered if adding a transverse abdominus plane block and intravenous acetaminophen to an established pathway would improve outcomes and resource use. OBJECTIVE The aim of this study was to evaluate the impact of modification of an enhanced recovery pathway on patient outcomes. DESIGN This was a case-matched study. METHODS After the addition of transverse abdominus plane blocks and acetaminophen to the enhanced recovery pathway 12 months ago, review of a prospective database was performed. Patients were matched by procedure type, age, and sex. SETTINGS This study was performed at a tertiary referral center. PATIENTS Patients undergoing elective major laparoscopic colorectal surgery from 2010 to 2012 were included. MAIN OUTCOME MEASURES The primary outcome measures were hospital length of stay, readmission rate, postoperative complications, and the cost of the hospital episode before and after the amendment of our enhanced recovery pathway. RESULTS Two hundred eight elective major laparoscopic cases were evaluated. Both groups were similar in demographics and comorbidities. Length of stay was significantly shorter once transverse abdominus plane blocks and acetaminophen were introduced (p < 0.01), dropping from 3.7 to 2.6 days. There were significantly more complications in the prechange group (p = 0.02), but no significant differences in readmissions or mortality. Direct costs were similar, but there was a $500 increase in total margin per case (p = 0.004) with the pathway changes. With the use of statistical process control to examine the effect on outliers, there was significantly less variation in the mean length of stay (2.29 vs 1.90 days, p < 0.01) after the addition of transverse abdominus plane blocks and intravenous acetaminophen. LIMITATIONS The single-surgeon, single-institution design was a limitation of this study. CONCLUSIONS The addition of a transverse abdominus plane block and acetaminophen significantly reduced length of stay more than that seen with a previously established pathway. Statistical process control demonstrated that our pathway changes significantly reduced the spread of outliers around our mean length of stay.

IntroductionOpioids prescribed after surgery accounted for 5% of the 191 million opioid prescriptions filled in 2017. Approximately 80% of the opioid pills prescribed by surgical care providers remain unused, leaving a substantial number of opioids available for non-medical use. We developed a multi-component intervention to address surgical providers’ role in the overprescribing of opioids. Our study will determine effective strategies for reducing post-surgical prescribing while ensuring adequate post-surgery patient-reported pain-related outcomes, and will assess implementation of the strategies.Methods and analysisThe Minimising Opioid Prescribing in Surgery study will implement a multi-component intervention, in an Illinois network of six hospitals (one academical, two large community and three small community hospitals), to decrease opioid analgesics prescribed after surgery. The multi-component intervention involves four domains: (1) patient expectation setting, (2) baseline assessment of opioid use, (3) perioperative pain control optimisation and (4) post-surgical opioid minimisation. Four surgical specialities (general, orthopaedics, urology and gynaecology) at the six hospitals will implement the intervention. A mixed-methods approach will be used to assess the implementation and effectiveness of the intervention. Data from the network’s enterprise data warehouse will be used to evaluate the intervention’s effect on post-surgical prescriptions and a survey will collect pain-related patient-reported outcomes. Intervention effectiveness will be determined using a triangulation design, mixed-methods approach with staggered speciality-specific implementation for contemporaneous control of opioid prescribing changes over time. The Consolidated Framework for Implementation Research will be used to evaluate the site-specific contextual factors and adaptations to achieve implementation at each site.Ethics and disseminationThe study aims to identify the most effective hospital-type and speciality-specific intervention bundles for rapid dissemination into our 56-hospital learning collaborative and in hospitals throughout the USA. All study activities have been approved by the Northwestern University Institutional Review Board (ID STU00205053).

Concerns persist regarding the effect of current surgical resident duty-hour policies on patient outcomes, resident education, and resident well-being.We conducted a national, cluster-randomized, pragmatic, noninferiority trial involving 117 general surgery residency programs in the United States (2014-2015 academic year). Programs were randomly assigned to current Accreditation Council for Graduate Medical Education (ACGME) duty-hour policies (standard-policy group) or more flexible policies that waived rules on maximum shift lengths and time off between shifts (flexible-policy group). Outcomes included the 30-day rate of postoperative death or serious complications (primary outcome), other postoperative complications, and resident perceptions and satisfaction regarding their well-being, education, and patient care.In an analysis of data from 138,691 patients, flexible, less-restrictive duty-hour policies were not associated with an increased rate of death or serious complications (9.1% in the flexible-policy group and 9.0% in the standard-policy group, P=0.92; unadjusted odds ratio for the flexible-policy group, 0.96; 92% confidence interval, 0.87 to 1.06; P=0.44; noninferiority criteria satisfied) or of any secondary postoperative outcomes studied. Among 4330 residents, those in programs assigned to flexible policies did not report significantly greater dissatisfaction with overall education quality (11.0% in the flexible-policy group and 10.7% in the standard-policy group, P=0.86) or well-being (14.9% and 12.0%, respectively; P=0.10). Residents under flexible policies were less likely than those under standard policies to perceive negative effects of duty-hour policies on multiple aspects of patient safety, continuity of care, professionalism, and resident education but were more likely to perceive negative effects on personal activities. There were no significant differences between study groups in resident-reported perception of the effect of fatigue on personal or patient safety. Residents in the flexible-policy group were less likely than those in the standard-policy group to report leaving during an operation (7.0% vs. 13.2%, P0.001) or handing off active patient issues (32.0% vs. 46.3%, P0.001).As compared with standard duty-hour policies, flexible, less-restrictive duty-hour policies for surgical residents were associated with noninferior patient outcomes and no significant difference in residents' satisfaction with overall well-being and education quality. (FIRST ClinicalTrials.gov number, NCT02050789.).

BACKGROUND: This study examined effects of health maintenance organization (HMO) penetration, hospital competition, and patient severity on the uptake of laparoscopic colectomy and its price relative to open surgery for colon cancer. METHODS: The MarketScan Database (data from 2002-2007) was used to identify admissions for privately insured colorectal cancer patients undergoing laparoscopic or open partial colectomy (n ¼ 1035 and n ¼ 6389, respectively). Patient and health plan characteristics were retrieved from these data; HMO market penetration rates and an index of hospital market concentration, the Herfindahl-Hirschman index (HHI), were derived from national databases. Logistic and logarithmic regressions were used to examine the odds of having laparoscopic colectomy, effect of covariates on colectomy prices, and the differential price of laparoscopy. RESULTS: Adoption of laparoscopy was highly sensitive to market forces, with a 10% increase in HMO penetration leading to a 10.9% increase in the likelihood of undergoing laparoscopic colectomy (adjusted odds ratio ¼ 1.109; 95% confidence interval [CI] ¼ 1.062, 1.158) and a 10% increase in HHI resulting in 6.6% lower likelihood (adjusted odds ratio ¼ 0.936; 95% CI ¼ 0.880, 0.996). Price models indicated that the price of laparoscopy was 7.6% lower than that of open surgery (transformed coefficient ¼ 0.927; 95% CI ¼ 0.895, 0.960). A 10% increase in HMO penetration was associated with 1.6% lower price (transformed coefficient ¼ 0.985; 95% CI ¼ 0.977, 0.992), whereas a 10% increase in HHI was associated with 1.6% higher price (transformed coefficient ¼ 1.016; 95% CI ¼ 1.006, 1.027; P < .001 for all comparisons). CONCLUSIONS: Laparoscopy was significantly associated with lower hospital prices. Moreover, laparoscopic surgery may result in cost savings, while market pressures contribute to its adoption. Cancer 2012;118:5741-8. V C 2012 American Cancer Society.

Background Surgical technique might influence rectal cancer survival, yet international practices for surgical treatment of rectal cancer are poorly described. Methods We performed a cross-sectional survey in a cohort of experienced colorectal surgeons representing 123 centers. Results Seventy-one percent responded, 70% are from departments performing more than 50 proctectomies annually. More than 50% defined the rectum as "15 cm from the verge." Seventy-two percent perform laparoscopic proctectomy, 80% use oral bowel preparation, 69% perform high ligation of the inferior mesenteric artery, 76% divert stomas as routine for colo-anal anastomosis, and 63% use enhanced recovery protocols. Different practices exist between US and non-US surgeons: 15 cm from the verge to define the rectum (34% vs 59%; P = .03), personally perform laparoscopic resection (82% vs 66%; P = .05), rectal stump washout (36% vs 73%; P = .0001), always drain after surgery (23% vs 42%; P = .03), transanal endoscopic microsurgery for T2N0 in medically unfit patients (39% vs 61%; P = .0001). Conclusions Wide international variations in rectal cancer management make outcome comparisons challenging, and consensus development should be encouraged.

Collagen anal fistula plug treatment of transsphincteric fistulas produces variable results. The purpose of our study was to determine whether long-tract fistulas (4 cm) correlated with successful closure.All patients undergoing transsphincteric cryptoglandular fistula repair with anal fistula plugs were enrolled in a prospective database. Patients with Crohn's disease were excluded. Fistula tract length was measured intraoperatively by subtracting the remaining plug length from the original plug size. All procedures used standardized techniques and postoperative care pathways. The primary outcome was complete fistula closure assessed through both postoperative outpatient visits and a follow-up telephone questionnaire.Forty-one patients with 42 fistula tracks were enrolled over a 39-month period. Complete closure was achieved in 18 of 42 (43%) fistulas at a mean follow-up of 25 months. Closure was not associated with gender, age, tract location, duration of seton, or length of follow-up. Successful closure was significantly associated with increased tract length, because fistulas longer than 4 cm were nearly 3 times more likely to heal compared with shorter fistulas ((14/23, 61%) vs (4/19, 21%), P = .004; relative risk = 2.8; 95% CI 1.14-7.03).Anal fistula plug repair of cryptoglandular anorectal fistulas is more successful for long-tract fistulas. Although the overall success is modest, limiting surgical indications to fistulas exceeding 4 cm may maximize benefits of the plug technique.

Purpose. Stereotactic body radiation therapy (SBRT) has emerged as a treatment option for local tumor control of primary and secondary malignancies of the liver. We report on our updated experience with SBRT in patients with non-resectable tumors of the liver. Methods. Our first 17 consecutive patients (mean age 58.1 years) receiving SBRT for HCC ( 𝑛 = 6 ), IHC ( 𝑛 = 3 ), and LM ( 𝑛 = 8 ) are presented. Mean radiation dose was 34Gy delivered over 1–3 fractions. Results. Treated patients had a mean decrease in maximum pretreatment tumor diameter from 6 . 9 ± 4 . 6 cm to 5 . 0 ± 2 . 1 cm at three months after treatment ( 𝑃 . 0 5 ). The mean total tumor volume reduction was 44% at six months ( 𝑃 . 0 5 ). 82% of all patients (14/17) achieved local control with a median follow-up of 8 months. 100% of patients with HCC ( 𝑛 = 6 ) achieved local control. Patients with surgically placed fiducial markers had no complications related to marker placement. Conclusion. Our preliminary results showed that SBRT is a safe and effective local treatment modality in selected patients with liver malignancies with minimal adverse events. Further studies are needed to define its role in the management of these malignancies.

INTRODUCTION: We used a publicly available limited data set from the National Surgical Quality Improvement Project to assess the preoperative risk factors and postoperative complication rates reported for laparoscopic colectomy and open colectomy. METHODS: Patients were evaluated from this nationally reported database who underwent either laparoscopic colectomy (n = 2728) or open colectomy (n = 4719) from December 1, 2005 through September 1, 2007. RESULTS: Body mass index was similar for laparoscopic (27.9, SD 5.8) and open colectomy patients (28.0, SD 7.2). The open colectomy group had significantly higher rates of diabetes (16.0 percent vs. 12.0 percent), smoking (18.0 percent vs. 15.0 percent), dyspnea (14.0 percent vs. 9.0 percent), chronic obstructive pulmonary disease (7.0 percent vs. 4.0 percent), congestive heart failure (2.0 percent vs. 0.6 percent), myocardial infarction within previous 6 months (0.9 percent vs. 0.4 percent), and hypertension (54 percent vs. 50 percent). All perioperative complications were more frequent in the open colectomy group; mortality (4.9 percent vs. 0.8 percent), surgical site infections (12 percent vs. 8.0 percent), wound disruption (2.0 percent vs. 0.8 percent), pneumonia (5.0 percent vs. 2.0 percent), and acute renal failure (1.0 percent vs. 0.3 percent). CONCLUSION: The data, derived from the publicly available limited data set from the National Surgical Quality Improvement Project audit process, suggest a higher rate for all commonly identified complications for open compared to laparoscopic colectomy; however, open colectomy patients have an apparent higher preoperative risk.

PURPOSE: This study was designed to identify the clinical features of anastomotic leakage after laparoscopic resection of rectal cancer and to evaluate the outcomes of laparoscopic management for this problem. METHODS: Prospectively collected data were obtained from 307 patients with rectal cancer who underwent laparoscopic proctectomy and primary anastomosis. Age, sex, tumor location, tumor stage, body mass index, comorbidities, ileostomy, conversion, intraoperative blood loss, operative time, previous abdominal operation, and hospital stay were analyzed for patients with or without anastomotic leakage. Management and outcome of anastomotic leakage also were analyzed. RESULTS: Anastomotic leakage occurred in 29 patients (9.4 percent). Diverting ileostomy was initially fashioned in 65 patients (21.2 percent). Leakage was related to young age, male sex, lower tumor location, and longer operation time. Ten patients (34.5 percent) were successfully managed with conservative treatment. Seventeen patients (58.6 percent) were managed via a laparoscopic approach. Open surgery was performed in two patients who showed diffuse fecal soiling or had previous conversion, respectively. There was no mortality. CONCLUSIONS: When leakage occurs, laparotomy or colostomy is not needed routinely. For surgical intervention, the abdominal cavity should be explored first by laparoscopic visualization because the majority of patients can be successfully managed with laparoscopy and ileostomy.

Laparoscopic colectomy (LC) is slowly becoming the standard of care for elective resections. However, the use of LC in the emergency setting is relatively unstudied. The authors describe their experience with a series of emergent and urgent LC cases for a variety of colorectal pathologies. This study reviewed 20 consecutive patients who had a laparoscopic emergent or urgent colectomy over a 2-year period. Patient demographics, indications for surgery, operative details, and postoperative complications were examined. Two cases were converted to open procedure, and the mean operative time was 162 min (median, 163 min). The average postoperative length of hospital stay was 8.1 days (median, 6 days). There was one reoperation and three readmissions within 30 days, with no mortality during the follow-up period. Six patients required intensive care unit (ICU) stays after surgery, and 40% of the patients had one or more postoperative complications. With increasing experience, LC is a feasible option in nonelective situations. Further prospective and comparative studies will improve our understanding of the outcomes for emergency LC.

In this study we evaluated the outcome of a standardized enhanced recovery program in patients undergoing ileostomy closure.Forty-two patients underwent ileostomy closure by a single surgeon and were managed by a standardized postoperative care pathway. On the first postoperative day, patients received oral analgesia and a soft diet. Discharge was based on standard criteria previously published for laparoscopic colectomy patients. Results were recorded prospectively in an Institutional Review Board-approved database, including demographics, operative time, blood loss, complications, length of stay, and readmission data.The median operative time and blood loss were 60 minutes and 17.5 mL, respectively, and median hospital stay was 2 days. Twenty-nine patients (69 percent) were discharged by postoperative Day 2. The complication rate was 23.8 percent; complications included prolonged postoperative ileus (n = 3), early postoperative small-bowel obstruction (n = 1), mortality not related to ileostomy closure (n = 1), minor bleeding (n = 1), wound infection (n = 1), incisional hernia (n = 1), diarrhea (n = 1), dehydration (n = 1). The 30-day readmission rate was 9.5 percent (n = 4). Two patients had reoperation within 30 days for small-bowel obstruction and a wound infection.Ileostomy closure patients managed with postoperative care pathways can have a short hospital stay with acceptable morbidity and readmission rates.

Background The US medical malpractice system assumes that the threat of liability should deter negligence, but it is unclear whether malpractice environment affects health care quality. We sought to explore the association between state malpractice environment and postoperative complication rates. Study Design This observational study included Medicare fee-for-service beneficiaries undergoing one of the following operations in 2010: colorectal, lung, esophageal, or pancreatic resection, total knee arthroplasty, craniotomy, gastric bypass, abdominal aortic aneurysm repair, coronary artery bypass grafting, or cystectomy. The state-specific malpractice environment was measured by 2010 medical malpractice insurance premiums, state average award size, paid malpractice claims/100 physicians, and a composite malpractice measure. Outcomes of interest included 30-day readmission, mortality, and postoperative complications (eg sepsis, myocardial infarction [MI], pneumonia). Using Medicare administrative claims data, associations between malpractice environment and postoperative outcomes were estimated using hierarchical logistic regression models with hospital random-intercepts. Results Measures of malpractice environment did not have significant, consistent associations with postoperative outcomes. No individual tort reform law was consistently associated with improved postoperative outcomes. Higher-risk state malpractice environment, based on the composite measure, was associated with higher likelihood of sepsis (odds ratio [OR] 1.22; 95% CI 1.07 to 1.39), MI (OR 1.14; 95% CI 1.06 to 1.23), pneumonia (OR 1.09; 95% CI 1.03 to 1.16), acute renal failure (OR 1.15; 95% CI 1.08 to 1.22), deep vein thrombosis/pulmonary embolism (OR 1.22; 95% CI 1.13 to 1.32), and gastrointestinal bleed (OR 1.18; 95% CI 1.08 to 1.30). Conclusions Higher risk malpractice environments were not consistently associated with a lower likelihood of surgical postoperative complications, bringing into question the ability of malpractice lawsuits to promote health care quality.

Background Changes to resident duty hour policies in the Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) trial could impact hospitalized patients' length of stay (LOS) by altering care coordination. Length of stay can also serve as a reflection of all complications, particularly those not captured in the FIRST trial (eg pneumothorax from central line). Programs were randomized to either maintaining current ACGME duty hour policies (Standard arm) or more flexible policies waiving rules on maximum shift lengths and time off between shifts (Flexible arm). Our objective was to determine whether flexibility in resident duty hours affected LOS in patients undergoing high-risk surgical operations. Study Design Patients were identified who underwent hepatectomy, pancreatectomy, laparoscopic colectomy, open colectomy, or ventral hernia repair (2014–2015 academic year) at 154 hospitals participating in the FIRST trial. Two procedure-stratified evaluations of LOS were undertaken: multivariable negative binomial regression analysis on LOS and a multivariable logistic regression analysis on the likelihood of a prolonged LOS (>75 th percentile). Results Before any adjustments, there was no statistically significant difference in overall mean LOS between study arms (Flexible Policy: mean [SD] LOS 6.03 [5.78] days vs Standard Policy: mean LOS 6.21 [5.82] days; p = 0.74). In adjusted analyses, there was no statistically significant difference in LOS between study arms overall (incidence rate ratio for Flexible vs Standard: 0.982; 95% CI, 0.939–1.026; p = 0.41) or for any individual procedures. In addition, there was no statistically significant difference in the proportion of patients with prolonged LOS between study arms overall (Flexible vs Standard: odds ratio = 1.028; 95% CI, 0.871–1.212) or for any individual procedures. Conclusions Duty hour flexibility had no statistically significant effect on LOS in patients undergoing complex intra-abdominal operations.

There are currently 2 widely accepted treatment strategies for patients presenting to the hospital with choledocholithiasis. However, the rate of use for each strategy in the United States has not been evaluated, and their trends over time have not been described. Furthermore, an optimal management strategy for choledocholithiasis has yet to be defined.To evaluate secular trends in the management of choledocholithiasis in the United States and to compare hospital length of stay between patients with choledocholithiasis treated with endoscopic retrograde cholangiopancreatography with laparoscopic cholecystectomy (ERCP+LC) vs laparoscopic common bile duct exploration with laparoscopic cholecystectomy (LCBDE+LC).In this cohort study, we studied patients with a primary diagnosis of choledocholithiasis that were included in the National Inpatient Sample between 1998 and 2013 from a representative sample of acute care hospitals in the United States. Patients with cholangitis or pancreatitis were excluded.Unadjusted and risk-adjusted median hospital length of stay.Of the 37 207 patients included in our analysis, 36 048 (96.9%) were treated with ERCP+LC and 1159 (3.1%) were treated with LCBDE+LC. The mean (SD) age of patients treated with ERCP+LC was 50.7 (21.1) years and was 51.9 (20.9) years for those treated with LCBDE+LC; 25 788 (69.3%) were female. Analysis of the National Inpatient Sample data indicates that there are an average of 26 158 patients with choledocholithiasis admitted in the United States each year. The overall use of CBDE for patients with choledocholithiasis decreased from 39.8% of admissions in 1998 to 8.5% in 2013 (P .001). A decrease was also seen for open CBDE (30.6% vs 5.5%; P .001) and laparoscopic CBDE (9.2% vs 3.0%; P .001) independently. Rates of management with LCBDE+LC decreased from 5.3% to 1.5% (P .001), while rates of ERCP+LC increased from 52.8% to 85.7% (P .001). The unadjusted median hospital length of stay was shorter for patients treated with LCBDE+LC than for those treated with ERCP+LC (3.0 vs 4.0 days; P .001). After risk-adjustment, the median length of stay remained 0.5 days shorter for patients treated with LCBDE+LC than with ERCP+LC (3.5 vs 4.0 days; P .001).This study highlights the marked decline in the use of both open and laparoscopic CBDE in the United States as well as the benefit to the length of stay LCBDE+LC has over ERCP+LC. Despite a persistent need for CBDE and the potential benefits of LCBDE+LC over ERCP+LC for managing choledocholithiasis, if current trends continue, CBDE may be at risk of disappearing from the surgical armamentarium.

The ability to perform a laparoscopic colectomy is an integral part of a young colorectal surgeon’s practice. However, the number of resections required during colorectal residency for a surgeon to be very comfortable performing a laparoscopic colectomy independently is poorly defined. Furthermore, the percentage of trainees that achieve this goal also is unknown. An electronic survey designed by the Young Surgeon’s Committee of the American Society of Colon and Rectal Surgeons (ASCRS) was sent to graduates completing Accreditation Council for Graduate Medical Education (ACGME) colorectal residencies after publication of the Clinical Outcomes Study Group (COST) trial (2004–2009). The data collected included the number of laparoscopic right (LR), laparoscopic left (LL), and laparoscopic hand-assisted left (HAL) colectomies performed during residency. Trainees were asked to assess whether at the completion of their fellowship they with each case were very comfortable (VC, would perform a laparoscopic colectomy independently), somewhat comfortable (SC, would require assistance from colleagues), or not comfortable (NC, would not perform a laparoscopic colectomy). Of the 176 (51%) former fellows responding to the survey, 42 (24%) reported performing fewer than 10 LRs, 108 (62%) reported 10 to 30 LRs, and 24 (14%) reported more than 30 LRs during their fellowship. With LR, 13 (7.5%) respondents were NC, 42 (21%) were SC, and 119 (68%) were VC. As reported, 58 fellows (33%) performed fewer than 10 LLs, 92 (53%) performed 10–30 LLs, and 22 (13%) performed more than 30 LLs. With LL, 12.2% were NC, 33.7% were SC, and 54.1% were VC. Most of the fellows (90%) who performed 30 or more LR, LL, or HAL colectomies were VC. On the average, each year’s graduating fellows were more comfortable with laparoscopic colectomy than those graduating in previous years (P

Context The Surgical Care Improvement Project (SCIP) aims to reduce surgical infectious complication rates through measurement and reporting of 6 infection-prevention process-of-care measures. However, an association between SCIP performance and clinical outcomes has not been demonstrated. Objective To examine the relationship between SCIP infection-prevention process-of-care measures and postoperative infection rates. Design, Setting, Participants A retrospective cohort study, using Premier Inc's Perspective Database for discharges between July 1, 2006 and March 31, 2008, of 405 720 patients (69% white and 11% black; 46% Medicare patients; and 68% elective surgical cases) from 398 hospitals in the United States for whom SCIP performance was recorded and submitted for public report on the Hospital Compare Web site. Three original infection-prevention measures (S-INF-Core) and all 6 infection-prevention measures (S-INF) were aggregated into 2 separate all-or-none composite scores. Hierarchical logistical models were used to assess process-of-care relationships at the patient level while accounting for hospital characteristics. Main Outcome Measure The ability of reported adherence to SCIP infection-prevention process-of-care measures (using the 2 composite scores of S-INF and S-INF-Core) to predict postoperative infections. Results There were 3996 documented postoperative infections. The S-INF composite process-of-care measure predicted a decrease in postoperative infection rates from 14.2 to 6.8 per 1000 discharges (adjusted odds ratio, 0.85; 95% confidence interval, 0.76-0.95). The S-INF-Core composite process-of-care measure predicted a decrease in postoperative infection rates from 11.5 to 5.3 per 1000 discharges (adjusted odds ratio, 0.86; 95% confidence interval, 0.74-1.01), which was not a statistically significantly lower probability of infection. None of the individual SCIP measures were significantly associated with a lower probability of infection. Conclusions Among hospitals in the Premier Inc Perspective Database reporting SCIP performance, adherence measured through a global all-or-none composite infection-prevention score was associated with a lower probability of developing a postoperative infection. However, adherence reported on individual SCIP measures, which is the only form in which performance is publicly reported, was not associated with a significantly lower probability of infection.

Background Chronic abdominal wall pain (CAWP) occurs in about 30% of all patients presenting with chronic abdominal pain. Methods The authors review the literature identified in a PubMed search regarding the abdominal wall as the origin of chronic abdominal pain. Results CAWP is frequently misinterpreted as visceral or functional abdominal pain. Misdiagnosis often leads to a variety of investigational procedures and even abdominal operations with negative results. With a simple clinical test (Carnett's test), >90% of patients with CAWP can be recognized, without risk for missing intra-abdominal pathology. Conclusion The condition can be confirmed when the injection of local anesthetics in the trigger point(s) relieves the pain. A fasciotomy in the anterior abdominal rectus muscle sheath through the nerve foramina of the affected branch of one of the anterior intercostal nerves heals the pain.

The Physician Quality Reporting Initiative (PQRI) is a pay-for-reporting (P4R) program sponsored by the Centers for Medicare & Medicaid Services open to all health care providers that treat Medicare patients. This P4R initiative provides financial incentives for participation and unlike most pay-for-performance (P4P) programs, there are no penalties for poor performance. PQRI therefore offers Medicare providers nationwide a low-risk opportunity to gain experience with reporting procedures likely to be incorporated into P4P reimbursement schemes. The 74 measures used during the first reporting period are applicable to both generalist and specialist providers and open participation in PQRI to a much broader audience compared with previous federal initiatives. Also in contrast to programs that measure hospital or group quality and reimburse for services at the health system level, measurement and reimbursement in PQRI directly affects individual Medicare providers. The combination of provider-level measurement and reimbursement and efforts to assess care delivered by both generalist and specialist Medicare providers highlights how this P4R initiative is truly a gateway to a P4P reimbursement system. Participation in the PQRI program provides useful experience to Medicare providers and their staff in preparing for future initiatives that try to tie quality to reimbursement.