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Background: Emergency general surgery (EGS) diseases are time-sensitive conditions that require urgent surgical evaluation, yet the effect of geographic access to care on outcomes remains unclear. We examined the association of spatial access with outcomes for common EGS conditions., Methods: A retrospective analysis of twelve 2014 State Inpatient Databases, identifying adults admitted with eight EGS conditions, was performed. We assessed spatial access using the spatial access ratio (SPAR)-an advanced spatial model that accounts for travel distance, hospital capacity, and population demand, normalized against the national mean. Multivariable regression models adjusting for patient and hospital factors were used to evaluate the association between SPAR with (a) in-hospital mortality and (b) major morbidity., Results: A total of 877,928 admissions, of which 104,332 (2.4%) were in the lowest-access category (SPAR, 0) and 578,947 (66%) were in the high-access category (SPAR, ≥1), were analyzed. Low-access patients were more likely to be White, male, and treated in nonteaching hospitals. Low-access patients also had higher incidence of complex EGS disease (low access, 31% vs. high access, 12%; p < 0.001) and in-hospital mortality (4.4% vs. 2.5%, p < 0.05). When adjusted for confounding factors, including presence of advanced hospital resources, increasing spatial access was protective against in-hospital mortality (adjusted odds ratio, 0.95; 95% confidence interval, 0.94-0.97; p < 0.001). Spatial access was not significantly associated with major morbidity., Conclusion: This is the first study to demonstrate that geospatial access to surgical care is associated with incidence of complex EGS disease and that increasing spatial access to care is independently associated with lower in-hospital mortality. These results support the consideration of spatial access in the development of regional health systems for EGS care., Level of Evidence: Prognostic and Epidemiologic; Level III., (Copyright © 2022 American Association for the Surgery of Trauma.)

Objectives: The Veterans Health Administration (VHA) is implementing a model of healthcare known as Whole Health (WH). The goal of WH is to shift from a disease-oriented system to one that emphasizes health promotion and disease prevention as well as promotes the use of Complementary and Integrative Health. The aim of this project was to investigate utilization and outcomes of WH programming among Veterans with psychiatric disorders., Design: This was a retrospective study. Subjects were 7138 Veterans who had a mental health diagnosis. Descriptive data, as well as within- and between-subjects analyses were conducted to investigate utilization and outcomes., Setting: The study was conducted at a large VHA medical center., Interventions: Whole health interventions considered in this study were mindfulness training, health education, wellbeing, and nutrition classes as well as health coaching. Other whole health interventions, such as acupuncture and message were not evaluated., Main Outcome Measures: Utilization of mental health treatment services, medication prescriptions, pain scores and suicide-related behaviors were the primary outcome measures., Results: There were 305 Veterans with at least one WH appointment. The existence of several specific psychiatric disorders was associated with WH utilization. The mean number of appointments completed per individual was 6.9 for all WH programming. Finally, WH participation was associated with decreased risk of suicide as well as reduced use of mental health services. There were no significant changes to other outcome variables., Conclusions: WH programming shows promise to reduce suicide risk and the need for mental health services among this population. Additionally, WH services were underutilized and there was a lack of treatment engagement., Competing Interests: Declarations of interest None., (Copyright © 2022. Published by Elsevier Ltd.)

Objective: This study aims to evaluate whether graduates of integrated vascular surgery residency (IVSR) programs achieve similar surgical outcomes in clinical practice as compared to graduates of vascular surgery fellowships (VSF)., Summary of Background Data: Early sub-specialization through IVSR programs decreases the total years of surgical training. However, it is unclear whether IVSR graduates achieve comparable outcomes to fellowship-trained surgeons once in clinical practice., Methods: We identified all vascular surgeons who finished IVSR and VSF programs between 2013-2017 using American Board of Surgery data, which was linked to the Vascular Quality Initiative registry (2013-2019) to evaluate provider-specific clinical outcomes following carotid, lower extremity, and aortic aneurysm repair procedures. The association between training models and the composite outcome of 1-year mortality, major adverse cardiac events and/or other major complications were analyzed using mixed-effects logistic regression models., Results: A total of 338 surgeons (31% IVSR, 69% VSF) submitted cases into the Vascular Quality Initiative registry, including 8155 carotid, 21,428 lower extremity, and 5800 aortic aneurysm repair procedures. Composite 1-year outcome rates were comparable between IVSR and VSF-trained surgeons following carotid endarterectomy (8%-IVSR vs 7%-VSF), lower extremity revascularization (19%-IVSR vs 16%-VSF), and aortic aneurysm repair (13%-IVSR vs 13%-VSF) procedures. These findings among IVSR-trained surgeons persisted following risk adjustment for severity of patient disease and indications for undertaking carotid [aOR: 1.04 (0.84-1.28)], lower extremity [aOR: 1.03 (0.84-1.26)], and aortic [aOR: 0.96 (0.76-1.21)] procedures when compared to VSF-trained surgeons., Conclusions: Despite fewer total years of training, graduates of IVSR programs achieve equivalent surgical outcomes as fellowship-trained vascular surgeons once in practice. These results suggest that concerns about differential competence among integrated residency graduates are not warranted., Competing Interests: The authors report no conflicts of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Background: It is unclear whether shortened training of integrated vascular surgery residencies (IVSR) has detrimental effects on graduates' performance. We sought to investigate whether there is a difference in frail patient outcomes based on the training paradigm completed by their surgeon., Methods: IVSR and vascular surgery fellowship (VSF)-trained surgeons were identified in the American Board of Surgery database and linked to the Vascular Quality Initiative registry (2013-2019) to evaluate provider-specific patient outcomes for frail patients following vascular procedures using mixed-effects logistic regression., Results: 105 IVSR graduates (31%) and 233 VSF graduates (69%) were included. Composite 1-year outcomes of frail patients were comparable between IVSR and VSF-trained surgeons following carotid endarterectomy (16%-IVSR vs 25%-VSF; p = 0.76), lower extremity revascularization (37%-IVSR vs 36%-VSF; p = 0.83), and aortic aneurysm repair (25%-IVSR vs 23%-VSF; p = 0.89)., Conclusions: The type of training paradigm completed by vascular surgeons was not associated with differences in their post-operative outcomes in frail patients., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: The purpose of the present study was to analyze the association between sex hormone deficiency and rotator cuff repair (RCR) with use of data from a large United States insurance database., Methods: A retrospective analysis of insured subjects from the Truven Health MarketScan database was conducted, collecting data for RCR cases as well as controls matched for age, sex, and years in the database. Multivariable logistic regression models adjusted for matching variables were utilized to compare RCR status with estrogen deficiency status and testosterone deficiency status. These associations were confirmed with use of data from the Veterans Genealogy Project database, with which the relative risk of RCR was estimated for patients with and without sex hormone deficiency., Results: The odds of RCR for female patients with estrogen deficiency were 48% higher (odds ratio, 1.48; 95% confidence interval, 1.44 to 1.51; p < 0.001) than for those without estrogen deficiency. The odds of RCR for males with testosterone deficiency were 89% higher (odds ratio, 1.89; 95% confidence interval, 1.82 to 1.96; p < 0.001) than for those without testosterone deficiency. Within the Veterans Genealogy Project database, the relative risk of estrogen deficiency among RCR patients was 2.58 (95% confidence interval, 2.15 to 3.06; p < 0.001) and the relative risk of testosterone deficiency was 3.05 (95% confidence interval, 2.67 to 3.47; p < 0.001)., Conclusions: Sex hormone deficiency was significantly associated with RCR. Future prospective studies will be necessary to understand the pathophysiology of rotator cuff disease as it relates to sex hormones., Level of Evidence: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJS/G944)., (Copyright © 2022 by The Journal of Bone and Joint Surgery, Incorporated.)

Abstract: Measuring patient satisfaction scores and interpreting factors that impact their variation is of importance as scores influence various aspects of health care administration. Our objective was to evaluate if Press Ganey scores differ between medical specialties.New patient visits between January 2014 and December 2016 at a single tertiary academic center were included in this study. Press Ganey scores were compared between specialties using a multivariable logistic mixed effects model. Secondary outcomes included a comparison between surgical versus non-surgical specialties, and pediatric versus adult specialties. Due to the survey's high ceiling effect, satisfaction was defined as a perfect total score.Forty four thousand four hundred ninety six patients met inclusion criteria. Compared to internal medicine, plastic surgery, general surgery, dermatology, and family medicine were more likely to achieve a perfect overall score, as, with odds ratios of 1.46 (P = .02), 1.29 (P = .002), 1.22 (P = .004), and 1.16 (P = .02) respectively. Orthopaedics, pediatric medicine, pediatric neurology, neurology, and pain management were less likely to achieve satisfaction with odds ratios of 0.85 (P = .047), 0.71 (P < .001), 0.63 (P = .005), 0.57 (P < .001), and 0.51 (P = .006), respectively. Compared to pediatric specialties, adult specialties were more likely to achieve satisfaction (OR 1.73; P < .001). There were no significant differences between surgical versus non-surgical specialties.Press Ganey scores systematically differ between specialties within the studied institution. These differences should be considered by healthcare systems that use patient satisfaction data to modify provider reimbursement., Competing Interests: The authors have no conflicts of interests to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Objective: The Vascular Surgery Board of the American Board of Surgery (VSB-ABS) Qualifying and Certifying examinations are meant to assess qualifications to independently practice vascular surgery, but it is unclear whether examination performance correlates with clinical outcomes. We assessed this relationship using clinical outcomes data for VSB-ABS diplomates from the Society for Vascular Surgery Vascular Quality Initiative (SVS-VQI)., Methods: VSB-ABS examination performance for vascular surgeons participating in the SVS-VQI registry was characterized according to pass/fail status. Surgical experience was measured by number of years since completion of training. Examination performance and experience were compared with a composite clinical outcome (in-patient major adverse cardiac events or postoperative death [MACE+POD]) after arterial reconstructions (carotid stenting or endarterectomy, aortic aneurysm repair, open peripheral surgical bypasses) registered in the SVS-VQI. Multivariate mixed effects regression was performed adjusting for sex and surgery type, as well as clustering by surgeon and by hospital., Results: From 2003 to 2017, complete data were available for 776 vascular surgeons who performed 124,171 arterial reconstructions (carotid n = 56,650; aortic n = 34,764; peripheral n = 32,757) registered in the SVS-VQI. Patient characteristics associated with higher odds of MACE+POD were female sex (odds ratio [OR] 1.07; 95% confidence interval [CI], 1.03-1.12; P = .006) and advancing age (OR, 1.04; 95% CI, 1.03-1.04; P < .001). Of the 776 surgeons, 149 (17%) had failed at least one VSB-ABS examination (group F). The unadjusted primary composite outcome of MACE+POD was marginally higher after operations performed by surgeons who never failed an examination (group P; 7% vs 6%; P = .03). This difference seems to be driven by higher rates of postoperative congestive heart failure in the aortic and lower extremity bypass cohorts as well as more postoperative myocardial infarctions after lower extremity bypass by group P surgeons. Following multivariable analyses, examination pass status was not associated with MACE+POD (OR, 0.98; 95% CI, 0.89-1.50; P = .517). However, increasing surgical experience correlated with significantly lower odds of MACE+POD (2% lower odds/year of experience since training [OR, 0.98; 95% CI, 0.98-0.99; P < .001])., Conclusions: VSB-ABS examination performance by SVS-VQI surgeons does not correlate with registry-reported mortality or cardiovascular complications. Increasing surgical experience is strongly associated with lower odds of cardiovascular morbidity and death., (Copyright © 2020 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: Gender disparity exists in medicine, such as differences in pay and promotion opportunities. We hypothesize that there is also a gender difference in graduate medical education as manifested by operative case volume. This study compares surgical case volume by gender for graduating US otolaryngology residents., Study Design: Cohort study., Methods: With data use approval from the Accreditation Council for Graduate Medical Education, we evaluated the key indicator case log summaries of graduating otolaryngology residents from 2009-2017. Mean and standard deviation were used for all cases, and t-tests were used to compare cases by resident gender. The Bonferroni method was used to adjust for multiple comparisons across years., Results: Data from 1740 male and 804 female residents were evaluated. Across all years, the average number of key indicator cases reported was 778.8 and 813.6 by female and male residents, respectively, with an average difference of 34.8 cases per graduating year (95% confidence interval [CI] 19.4, 50.2; P < .001). When a resident self-reported the role of resident surgeon/supervisor, the average number of key indicator cases reported was 602.6 and 643.9 by female and male residents, respectively, with an average difference of 41.3 cases per graduating year (95% CI, 28.0, 54.6; P < .001)., Conclusion: Gender-based discrepancies in surgical case volume exist among graduating otolaryngology residents. This disparity is partially attributed to the self-reported role in the surgery. This study has identified those discrepancies so that training programs can implement strategies to ensure improved gender parity., Level of Evidence: 2b Laryngoscope, 130:1651-1656, 2020., (© 2019 The American Laryngological, Rhinological and Otological Society, Inc.)

BACKGROUND Outcomes from extracorporeal cardiopulmonary resuscitation (ECPR) are felt to be influenced by selective use, but the characteristics of those receiving ECPR are undefined. We demonstrate the relationship between individual patient and hospital characteristics and the probability of ECPR use. METHODS AND RESULTS We performed an observational analysis of adult inpatient cardiac arrests in the United States from 2000 to 2018 reported to the American Heart Association's Get With The Guidelines-Resuscitation registry restricted to hospitals that provided ECPR. We calculated case mix adjusted relative risk (RR) of receiving ECPR for individual characteristics. From 2000 to 2018, 129 736 patients had a cardiac arrest (128 654 conventional cardiopulmonary resuscitation and 1082 ECPR) in 224 hospitals that offered ECPR. ECPR use was associated with younger age (RR, 1.5 for <40 vs. 40-59 years; 95% CI, 1.2-1.8), no pre-existing comorbidities (RR, 1.4; 95% CI, 1.1-1.8) or cardiac-specific comorbidities (congestive heart failure [RR, 1.3; 95% CI, 1.2-1.5], prior myocardial infarction [RR, 1.4; 95% CI, 1.2-1.6], or current myocardial infarction [RR, 1.5; 95% CI, 1.3-1.8]), and in locations of procedural areas at the times of cardiac arrest (RR, 12.0; 95% CI, 9.5-15.1). ECPR decreased after hours (3-11 pm [RR, 0.8; 95% CI, 0.7-1.0] and 11 pm-7 am [RR, 0.6; 95% CI, 0.5-0.7]) and on weekends (RR, 0.7; 95% CI, 0.6-0.9). CONCLUSIONS Less than 1% of in-hospital cardiac arrest patients are treated with ECPR. ECPR use is influenced by patient age, comorbidities, and hospital system factors. Randomized controlled trials are needed to better define the patients in whom ECPR may provide a benefit.

Background: We sought to examine patterns of readmission after nonoperative trauma, including rates of delayed operative intervention and mortality., Methods: The Nationwide Readmissions Database (2013-2014) was queried for all adult trauma admissions and 30-day readmissions. Index admissions were classified as operative (OI) or nonoperative (NOI), and readmissions examined for major operative intervention (MOR). Multivariable regression modeling was used to evaluate risk for readmission requiring MOR and in-hospital mortality., Results: Of 2,244,570 trauma admissions, there were 59,573 readmissions: 66% after NOI, and 35% after OI. Readmission rate was higher after NOI compared with OI (3.6% vs. 1.7% p < 0.001). Readmitted NOI patients were older, with a higher proportion of Injury Severity Score ≥15 and were readmitted earlier (NOI median 8 days vs. OI 11 days). Thirty-one percent of readmitted NOI patients required MOR and experienced higher overall mortality compared with OI patients with operative readmission (NOI 2.9% vs. OI 2%, p = 0.02). Intracranial hemorrhage was an independent risk factor for NOI readmission requiring MOR in both the overall (hazard ratio, 1.11; 95% confidence interval [CI], 1.01-1.22) and Injury Severity Score of 15 or greater cohorts (hazard ratio, 1.46; 95% CI, 1.24-1.7), with a predominance of nonspine neurosurgical procedures (20.3% and 55.1%, respectively). Operative readmission after NOI cost a median of $17,364 (interquartile range, US $11,481 to US $27,816) and carried a total annual cost of US $147 million (95% CI, US $141 million to $154 million)., Conclusions: Nonoperative trauma patients have a higher readmission rate than operative index patients and nearly one third require operative intervention during readmission. Operative readmission carries a higher overall mortality rate in NOI patients and together accounts for nearly US $150 million in annual costs., Level of Evidence: Epidemiological, level III.

Background: U.S. orthopaedic residency training is anchored by the Accreditation Council for Graduate Medical Education (ACGME) requirements, which include minimum numbers for 15 categories of procedures. The face validity of these recommendations and expectations for exposure to other common procedures has not been rigorously investigated. The main goals of this investigation were to understand the perceptions of program directors and early practice surgeons regarding the number of cases needed in residency training and to report which of the most commonly performed procedures residents should be able to perform independently upon graduation., Methods: We sent surveys to 157 current program directors of ACMGE-approved orthopaedic surgery residency programs and to all examinees sitting for the American Board of Orthopaedic Surgery (ABOS) Part II Oral Examination in 2017, requesting that they estimate the minimum number of exposures for the 22 adult and 24 pediatric procedures that are most commonly performed during residency and the first 2 years in practice. Where applicable, we compared these with the ACGME "Minimum Numbers" and the average ACGME resident experience data from 2010 to 2012 for resident graduates. For each of the 46 procedures, participants were asked if every orthopaedic resident should be able to independently perform the procedure upon graduation. We compared the percent for independence between the early practice surgeons and the program directors., Results: For the majority of adult and pediatric procedures, the early practitioners reported significantly higher numbers of cases needing to be performed during residency than the program directors. ACGME Minimum Numbers were always lower than the case numbers that were recommended by the early practice surgeons and the program directors. Overall we found good-to-excellent agreement for independence at graduation between program directors and early practitioners for adult cases (intraclass correlation coefficient [ICC], 0.98; 95% confidence interval [CI], 0.82 to 0.99) and moderate-to-good agreement for pediatric cases (ICC, 0.96; 95% CI, 0.74, 0.99)., Conclusions: The program directors frequently perceived the need for resident operative case exposure to common orthopaedic procedures to be lower than that estimated by the early practice surgeons. Both program directors and early practice surgeons generally agreed on which common cases residents should be able to perform independently by graduation.

Background: The management of high-grade renal trauma (HGRT) and the indications for intervention are not well defined. The American Association for the Surgery of Trauma (AAST) renal grading does not incorporate some important clinical and radiologic variables associated with increased risk of interventions. We aimed to use data from a multi-institutional contemporary cohort to develop a nomogram predicting risk of interventions for bleeding after HGRT., Methods: From 2014 to 2017, data on adult HGRT (AAST grades III-V) were collected from 14 level 1 trauma centers. Patients with both clinical and radiologic data were included. Data were gathered on demographics, injury characteristics, management, and outcomes. Clinical and radiologic parameters, obtained after trauma evaluation, were used to predict renal bleeding interventions. We developed a prediction model by applying backward model selection to a logistic regression model and built a nomogram using the selected model., Results: A total of 326 patients met the inclusion criteria. Mechanism of injury was blunt in 81%. Median age and injury severity score were 28 years and 22, respectively. Injuries were reported as AAST grades III (60%), IV (33%), and V (7%). Overall, 47 (14%) underwent interventions for bleeding control including 19 renal angioembolizations, 16 nephrectomies, and 12 other procedures. Of the variables included in the nomogram, a hematoma size of 12 cm contributed the most points, followed by penetrating trauma mechanism, vascular contrast extravasation, pararenal hematoma extension, concomitant injuries, and shock. The area under the receiver operating characteristic curve was 0.83 (95% confidence interval, 0.81-0.85)., Conclusion: We developed a nomogram that integrates multiple clinical and radiologic factors readily available upon assessment of patients with HGRT and can provide predicted probability for bleeding interventions. This nomogram may help in guiding appropriate management of HGRT and decreasing unnecessary interventions., Level of Evidence: Prognostic and epidemiological study, level III.

Background: In situ decompression, subcutaneous transposition, and submuscular transposition for cubital tunnel syndrome have historically yielded similar outcomes. The authors' null hypothesis is that no differences exist in surgical encounter total direct costs for in situ decompression, subcutaneous transposition, and submuscular transposition., Methods: Adult patients treated surgically for cubital tunnel syndrome by four fellowship-trained hand surgeons between August of 2011 and December of 2016 were identified by CPT code (64718) at their tertiary academic institution. Patients with prior elbow surgery or fracture/dislocation and those undergoing revision or additional simultaneous procedures were excluded. Using their institution's information technology value tools, the authors extracted prospectively collected surgical encounter total direct costs data for each surgical encounter. Costs were compared between groups and modeled using univariate and multivariable gamma regression., Results: In situ decompression, subcutaneous transposition, and submuscular transposition were performed on 45, 62, and 14 unique surgical encounters, respectively, with mean surgical times of 28.0, 46.5, and 50.0 minutes, respectively. Costs differed significantly between surgical methods. Surgical method and provider significantly affected surgical encounter total direct costs in the univariate model. Multivariable modeling demonstrated that subcutaneous transposition was 1.18-fold more costly than in situ decompression and submuscular transposition was 1.55-fold more costly than in situ decompression while controlling for age, sex, and provider., Conclusions: Surgical costs differed significantly between in situ decompression, subcutaneous transposition, and submuscular transposition. Given historically similar outcomes reported for these techniques, cost differences should be considered in addition to clinical factors to inform surgical decision-making for cubital tunnel syndrome patients.

Respiratory viral infections in infants undergoing congenital heart surgery lead to prolonged intubation time, hospital (HLOS) and cardiac intensive care unit length of stay (CICU LOS). The objective of this study was to evaluate the prevalence of respiratory viruses using molecular testing in otherwise healthy infants presenting for low complexity heart surgery, and to evaluate the impact of a positive viral screen and study questionnaire on post-surgical HLOS, CICU LOS, intubation time, respiratory complications, and oxygen therapy at home discharge. Sixty-nine infants (1 month to 1 year) undergoing cardiac surgery from November to May of the years 2012 to 2014 were prospectively enrolled, surveyed and tested. We compared the outcomes of positive molecular testing and positive study questionnaire to test negative subjects. We also evaluated the predictive value of study questionnaire in identification of viruses by molecular testing. Of the 69 enrolled infants, 58 had complete information available for analysis. 17 (30%) infants tested positive by molecular testing for respiratory pathogens. 38 (65%) had a "positive" questionnaire. Among the 20 viruses detected, Human Rhinovirus was the most common 12 (60%). Seven (12%) of the 58 patients developed respiratory symptoms following surgery prompting molecular testing. Four of these tested positive for a respiratory virus post-surgically. Neither positive molecular testing nor a positive questionnaire prior to surgery was associated with greater post-operative HLOS, CICU LOS, intubation time, respiratory complications, or use of oxygen at discharge compared to negative testing. The questionnaire poorly predicted positive molecular testing. Routine screening for respiratory viruses in asymptomatic infants may not be an effective strategy to predict infants at risk of post-operative complications.

Objective: Optimizing medical management through glucose control, smoking cessation, and drug therapy (ie, antiplatelet and statin agents) is recommended as first-line therapy for patients with claudication. The aims of this study were to determine how frequently veterans with claudication received optimal medical management (OMM) before undergoing elective open lower extremity bypass procedures nationwide and whether preoperative OMM was associated with improved surgical outcomes., Methods: We reviewed all patients within the Veterans Affairs (VA) Surgical Quality Improvement Program database who underwent elective open lower extremity bypass procedures for claudication at nationwide VA medical centers from 2005 until 2015. We defined OMM as a claudicant's having documentation of receiving all of the following within 12 months before surgery: prescriptions for antiplatelet, statin, and smoking cessation therapy (if a smoker) and monitoring of hemoglobin A 1c (if diabetic). Outcome measures included occurrence of any 30-day VA Surgical Quality Improvement Program complication, amputation-free survival, and 30-day and 1-year mortality. We used multivariate regression and Cox proportional hazards models incorporating inverse probability treatment weighting to analyze the effect of OMM on outcome measures after adjusting for patient-level confounding., Results: Among 10,271 lower extremity bypass procedures performed, 2265 (22%) were undertaken in claudicants with a median age of 63 years (interquartile range, 58-68 years). Of claudicants, 839 (37%) were diabetic, and 1333 (59%) patients smoked within 12 months before surgery. OMM was achieved in only 581 (26%) claudicants before they underwent surgery, although adherence to individual components was variable: antiplatelet, 55%; statin, 63%; smoking cessation, 58%; and hemoglobin A 1c monitoring, 92%. In risk-adjusted analyses, there were no statistically significant differences in complication rates, amputation-free survival, or mortality outcomes among patients who received OMM compared with non-OMM patients., Conclusions: Only a quarter of veterans with claudication were documented as receiving OMM within the year before undergoing open lower extremity bypass across nationwide VA medical centers, highlighting the need for strategies to ensure that medical therapy is intensified before surgical revascularization. Nevertheless, our data showed that documentation of preoperative OMM did not lead to improved short- or long-term postoperative outcomes in these patients, suggesting that more objective measures of medical management are needed to ensure that peripheral arterial disease goals are achieved., (Published by Elsevier Inc.)

Background: Understanding the variation in costs of endoscopic sinus surgery (ESS) is critical to defining value. Current published costs of ESS have not identified potential sources of variation. Our objective was to analyze ESS costs to identify sources of variance that could guide value-improving decisions., Methods: ESS cases (n = 1739) performed between 2008 and 2016 were identified from a database of 22 rural to tertiary facilities. Cost and time data were extracted from the database. Medical records were reviewed to confirm procedures. Three bilateral groupings were examined (n = 895 cases from 13 facilities): (1) full ESS (all sinuses); (2) intermediate ESS (total ethmoid, maxillary); and (3) anterior ESS (anterior ethmoid, maxillary). Cost and operative time were analyzed using multivariable gamma regression., Results: Median costs for full, intermediate, and anterior ESS were $4281, $3716, and $2549 U.S. dollars (p < 0.001). Median durations were 87, 60, and 58 minutes (p < 0.001). Among patients with no additional procedures, those with full ESS had operative duration, total cost, and supply costs that were 1.37 (95% confidence interval [CI], 1.17 to 1.61), 1.52 (95% CI, 1.32 to 1.75), and 2.40 (95% CI, 1.76 to 3.25) times greater than anterior ESS, respectively (all p < 0.001). Intermediate ESS duration at community urban facilities was 1.87 (95% CI, 1.74 to 2.02) times that of community rural facilities (p < 0.001)., Conclusion: Duration of surgery, extent of surgery, and location of surgery are sources of significant variation in the cost of ESS. These findings will assist healthcare policy makers, hospitals, and surgeons in optimizing the value of ESS., (© 2018 ARS-AAOA, LLC.)

Purpose: Carpal tunnel release (CTR) is a common surgical procedure, representing a financial burden to the health care system. The purpose of this study was to test whether the choice of CTR technique (open carpal tunnel release [OCTR] vs endoscopic carpal tunnel release [ECTR]), surgical setting (operating room vs procedure room [PR]), and anesthetic type (local, monitored anesthesia care [MAC], Bier block, general) affected costs or payments., Methods: Consecutive adult patients undergoing isolated unilateral CTR between July 2014, and October 2017, at a single academic medical center were identified. Patients undergoing ECTR converted to OCTR, revision surgery, or additional procedures were excluded. Using our institution's information technology value tools, we calculated total direct costs (TDCs), total combined payment (TCP), hospital payment, surgeon payment, and anesthesia payment for each surgical encounter. Cost data were normalized using each participant's surgical encounter cost divided by the average cost in the data set and compared across 8 groups (defined by surgery type, operation location, and anesthesia type)., Results: Of 479 included patients, the mean age was 55.3 ± 16.1 years, and 68% were female. Payer mix included commercial (45%), Medicare (37%), Medicaid (13%), workers' compensation (2%), self-pay (1%), and other (3%) insurance types. The TDC and TCP both differed significantly between each CTR group, and OCTR in the PR under local anesthesia was the lowest. The OCTR/local/operating room, OCTR/MAC/operating room, and ECTR/operating room, were associated with 6.3-fold, 11.0-fold, and 12.4-16.6-fold greater TDC than OCTR/local/PR, respectively., Conclusions: Performing OCTR under local anesthetic in the PR setting significantly minimizes direct surgical encounter costs relative to other surgical methods (ECTR), anesthetic methods (Bier block, MAC, general), and surgical settings (operating room)., Clinical Relevance: This study identifies modifiable factors that may lead to cost reductions for CTR surgery., (Copyright © 2018 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Background: The goal of surgical education is to prepare the trainee for independent practice; however, the relevance of the current residency experience to practice remains uncertain. The purpose of this study was to identify the surgical procedures most frequently performed in orthopaedic residency and in early surgical practice and to identify surgical procedures performed more often or less often in orthopaedic residency compared with early surgical practice., Methods: This retrospective cohort study included American Medical Association (AMA) Current Procedural Terminology (CPT) codes (n = 4,329,561 procedures) reported by all U.S. orthopaedic surgery residents completing residency between 2010 and 2012 (n = 1,978) and AMA CPT codes for all procedures (n = 413,370) reported by U.S. orthopaedic surgeons who took the American Board of Orthopaedic Surgery Part II certifying examination between 2013 and 2015 (n = 2,205). Relative rates were determined for AMA CPT codes and AMA CPT code categories for adult and pediatric surgeries that had frequencies of ≥0.1% for both practitioners and residents., Results: The top 25 adult AMA CPT code categories contributed 82.1% of the total case volume for residents and 82.4% for practitioners. Knee and shoulder arthroscopy were the most frequently performed procedures in adults in both residency and early practice. Humerus/elbow fracture and/or dislocation procedures and "other musculoskeletal-introduction or removal" procedures were the most frequently performed procedures in pediatric cases in both residency and early practice. Of the total 78 adult and 82 pediatric code categories included in our analysis that had a frequency of >1% in residency or early practice, there were 4 adult and 6 pediatric code categories demonstrating 44% to 1,164% greater frequency in residency than in early practice, and there were 8 adult and 7 pediatric code categories demonstrating 26% to 73% less frequency in residency than in early practice., Conclusions: Similarity between residency and early practice experience is generally strong. However, we identified several AMA CPT code categories and individual CPT codes for which the level of exposure during residency varied substantially from early practice experience. These findings can help residencies ensure adequate trainee exposure to procedures performed commonly in early practice.

Objectives: To investigate the variation in care and cost of spinal fusion for adolescent idiopathic scoliosis (AIS), and to identify opportunities for improving healthcare value., Study Design: Retrospective cohort study from the Pediatric Health Information Systems database, including children 11-18 years of age with AIS who underwent spinal fusion surgery between 2004 and 2015. Multivariable regression was used to evaluate the relationships between hospital cost, patient outcomes, and resource use., Results: There were 16 992 cases of AIS surgery identified. There was marked variation across hospitals in rates of intensive care unit admission (0.5%-99.2%), blood transfusions (0%-100%), surgical complications (1.8%-32.3%), and total hospital costs ($31 278-$90 379). Hospital cost was 32% higher at hospitals that most frequently admitted patients to the intensive care unit (P = .009), and 8% higher for each additional 25 operative cases per hospital (P = .003). Hospital duration of stay was shorter for patients admitted to hospitals with highest intensive care unit admission rates and higher surgical volumes. There was no association between cost and duration of stay, 30-day readmission, or surgical complications. The largest contribution to hospital charges was supplies (55%). Review of a single hospital's detailed cost accounting system also found supplies to be the greatest single contributor to cost, the majority of which were for spinal implants, accounting for 39% of total hospital costs., Conclusions: The greatest contribution to AIS surgery cost was supplies, the majority of which is likely attributed to spinal implant costs. Opportunities for improving healthcare value should focus on controlling costs of spinal instrumentation, and improving quality of care with standardized treatment protocols., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Purpose: With improving short-term mortality in acute respiratory distress syndrome (ARDS), understanding survivors' posthospitalisation outcomes is increasingly important. However, little is known regarding associations among physical, cognitive and mental health outcomes. Identification of outcome subtypes may advance understanding of post-ARDS morbidities., Methods: We analysed baseline variables and 6-month health status for participants in the ARDS Network Long-Term Outcomes Study. After division into derivation and validation datasets, we used weighted network analysis to identify subtypes from predictors and outcomes in the derivation dataset. We then used recursive partitioning to develop a subtype classification rule and assessed adequacy of the classification rule using a kappa statistic with the validation dataset., Results: Among 645 ARDS survivors, 430 were in the derivation and 215 in the validation datasets. Physical and mental health status, but not cognitive status, were closely associated. Four distinct subtypes were apparent (percentages in the derivation cohort): (1) mildly impaired physical and mental health (22% of patients), (2) moderately impaired physical and mental health (39%), (3) severely impaired physical health with moderately impaired mental health (15%) and (4) severely impaired physical and mental health (24%). The classification rule had high agreement (kappa=0.89 in validation dataset). Female Latino smokers had the poorest status, while male, non-Latino non-smokers had the best status., Conclusions: We identified four post-ARDS outcome subtypes that were predicted by sex, ethnicity, pre-ARDS smoking status and other baseline factors. These subtypes may help develop tailored rehabilitation strategies, including investigation of combined physical and mental health interventions, and distinct interventions to improve cognitive outcomes., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Background: The Press Ganey® Medical Practice Survey ("Press Ganey® survey") is a patient-reported questionnaire commonly used to measure patient satisfaction with outpatient health care in the United States. Our objective was to evaluate the reliability and validity of the Press Ganey® survey in a single institution setting., Methods: We analyzed surveys from 34,503 unique respondents seen by 624 providers from 47 specialties and 94 clinics at the University of Utah in 2013. The University of Utah is a health care system that provides primary through tertiary care for over 200 medical specialties. Surveys were administered online. The Press Ganey® survey consisted of 24 items organized into 6 scales: Access (4 items), Moving Through the Visit (2), Nurse Assistant (2), Care Provider (10), Personal Issues (4) and Overall Assessment (2). Missingness, ceiling and floor rates were summarized. Cronbach's alpha was used to evaluate internal consistency reliability. Confirmatory factor analysis was used to assess convergent and discriminant validities., Results: Missingness was 0.01% for the total score and ranged from 0.8 to 11.4% across items. The ceiling rate was high at 29.3% for the total score, and ranged from 55.4 to 84.1% across items. Floor rates were 0.01% for the total score, and ranged from 0.1 to 2.1% across items. Internal consistency reliability ranged from 0.79 to 0.96, and item-scale correlations ranged from 0.49 to 0.9. Confirmatory factor analysis supported convergent and discriminant validities., Conclusion: The Press Ganey® survey demonstrated suitable psychometric properties for most metrics. However, the high ceiling rate can have a notable impact on quarterly percentile scores within our institution. Multi-institutional studies of the Press Ganey® survey are needed to inform administrative decision making and institution reimbursement decisions based on this survey.

Introduction: Enterocystoplasty is an important procedure in the management of children with difficult neurogenic bladder. We report on short-term complications as captured by National Surgical Quality Improvement Program (NSQIP) Pediatric., Methods: We analyzed NSQIP Pediatric 30-day perioperative data on 114 patients who underwent enterocystoplasty in 2012 and compared those with and without complications., Results: Neurogenic bladder was the most common diagnosis. The proportion of the children who underwent two or more procedures was 71.9%, in addition to enterocystoplasty, most commonly appendicovesicostomy. Median length of hospital stay was 8 days (mean 9.7 days, range 2 to 46 days). Thirty-day complication rate was 33.3%, and the most common complications were urinary tract infections (9.6%), wound complications (8.7%), blood transfusions (6.1%), and sepsis (3.5%). Reoperation rate and readmission rate were 9.6% and 13.2%, respectively. No statistically significant differences in perioperative characteristics were found between children with and without postoperative complications. Addition of appendicovesicostomy or bladder neck continence procedures was not associated with significantly increased complications., Conclusion: Enterocystoplasty is associated with significant perioperative morbidity, and reasonable expectations should be set during preoperative counseling., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Introduction: Most high-grade renal injuries (American Association for Surgery of Trauma (AAST) grades III-V) result from motor vehicle collisions associated with numerous concomitant injuries. Sports-related blunt renal injury tends to have a different mechanism, a solitary blow to the flank. We hypothesized that high-grade renal injury is often isolated in sports-related renal trauma., Material and Methods: We identified patients with AAST grades III-V blunt renal injuries from four level 1 trauma centres across the United States between 1/2005 and 1/2014. Patients were divided into "Sport" or "Non-sport" related groups. Outcomes included rates of hypotension (systolic blood pressure <90mm Hg), tachycardia (>110bpm), concomitant abdominal injury, and procedural/surgical intervention between sports and non-sports related injury., Results: 320 patients met study criteria. 18% (59) were sports-related injuries with the most common mechanisms being skiing, snowboarding and contact sports (25%, 25%, and 24%, respectively). Median age was 24 years for sports and 30 years for non-sports related renal injuries (p=0.049). Males were more commonly involved in sports related injuries (85% vs. 72%, p=0.011). Median injury severity score was lower for sports related injuries (10 vs. 27, p<0.001). There was no difference in renal abbreviated injury scale scores. Sports related trauma was more likely to be isolated without other significant injury (69% vs. 39% (p<0.001)). Haemodynamic instability was present in 40% and 51% of sports and non-sports renal injuries (p=0.30). Sports injuries had lower transfusion (7% vs. 47%, p<0.001) and lower mortality rates (0% vs. 6%, p=0.004). There was no difference in renal-specific procedural interventions between the two groups (17% sports vs. 18% non-sports, p=0.95)., Conclusions: High-grade sports-related blunt renal trauma is more likely to occur in isolation without other abdominal or thoracic injuries and clinicians must have a high suspicion of renal injury with significant blows to the flank during sports activities., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Interleukins (ILs) are key regulators of immune response. Genetic variation in IL genes may influence breast cancer risk and mortality given their role in cell growth, angiogenesis and regulation of inflammatory process. We examined 16 IL genes with breast cancer risk and mortality in an admixed population of Hispanic/Native American (NA) (2111 cases and 2597 controls) and non-Hispanic white (NHW) (1481 cases and 1585 controls) women. Adaptive Rank Truncated Product (ARTP) analysis was conducted to determine gene significance and lasso (least absolute shrinkage and selection operator) was used to identify potential gene by gene and gene by lifestyle interactions. The pathway was statistically significant for breast cancer risk overall (P ARTP = 0.0006), for women with low NA ancestry (P(ARTP) = 0.01), for premenopausal women (P(ARTP) = 0.02), for estrogen receptor (ER)+/progesterone receptor (PR)+ tumors (P(ARTP) = 0.03) and ER-/PR- tumors (P(ARTP) = 0.02). Eight of the 16 genes evaluated were associated with breast cancer risk (IL1A, IL1B, IL1RN, IL2, IL2RA, IL4, IL6 and IL10); four genes were associated with breast cancer risk among women with low NA ancestry (IL1B, IL6, IL6R and IL10), two were associated with breast cancer risk among women with high NA ancestry (IL2 and IL2RA) and four genes were associated with premenopausal breast cancer risk (IL1A, IL1B, IL2 and IL3). IL4, IL6R, IL8 and IL17A were associated with breast cancer-specific mortality. We confirmed associations with several functional polymorphisms previously associated with breast cancer risk and provide support that their combined effect influences the carcinogenic process., (© The Author 2014. Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Objective: To calculate a reliable estimate of the population prevalence of Down syndrome in the US., Study Design: The annual number of births of infants with Down syndrome were estimated by applying published birth prevalence rates of Down syndrome by maternal age to US data from the Centers for Disease Control and Prevention for the years for which births by maternal age were available (1940-2008). Death certificate data for persons with Down syndrome were available for the years 1968-2007. We estimated the number of people with Down syndrome on January 1, 2008, using a life table approach based on proportions of deaths by age. Monte Carlo sampling was used to create 90% uncertainty intervals (UIs) for our estimates., Results: We estimated the January 1, 2008, population prevalence of Down syndrome as approximately 250700 (90% UI, 185900-321700) based on proportions of deaths by age from the most recent 2 years (2006-2007) of death certificate data. This estimate corresponds to a prevalence of 8.27 people with Down syndrome per 10000 population (90% UI, 6.14-10.62)., Conclusion: Our estimate of Down syndrome prevalence is roughly 25%-40% lower than estimates based solely on current birth prevalence. The results presented here can be considered a starting point for facilitating policy and services planning for persons with Down syndrome., (Copyright © 2013 Mosby, Inc. All rights reserved.)