38.09 Put Me in the Game Coach! Resident Participation in High Risk Surgery in the Big Data Era

Posted on January 18, 2018

A. N. Cobb1, E. Eguia1, P. C. Kuo1  1Loyola University Medical Center,General Surgery,Maywood, IL, USA

 Introduction: General surgery resident participation continues to be an important topic of conversation regarding resident education, particularly with the more restrictive 80 hour work week and emphasis on quality metrics guiding reimbursement. Previous literature has shown that resident participation does not negatively impact patient outcomes in low risk procedures. The aim of this study was to confirm that resident participation remains safe, as well as to explore changes in postoperative outcomes over time for high risk general surgery procedures (those where residents may get fewer opportunities to actively participate) cases performed with resident physicians.

Methods:
The National Surgical Quality Improvement Program database (2005-2012) was used to identify patients undergoing one of five high risk procedures: esophagectomy, open abdominal aortic aneurysm repair, laparoscopic paraesophageal hernia repair with Nissen fundoplication, pancreaticoduodenectomy, abdominoperineal resection, and hepatectomy. Outcomes were compared for patients with and without resident participation. Groups were created using a 2:1 propensity score match on the basis of age, sex, race, morbidity probability, ASA class, surgical specialty, comorbidities, and procedures. Postoperative outcomes were calculated using univariate statistics; chi square and ttest for categorical and continuous variables respectively. Trends in outcome over time were assessed using the Cochrane-Armitage test for trend. Predictors of mortality and overall complications were analyzed using decision tree analysis.

Results:
25,363 patients met our inclusion criteria. Following matching, the res and non-res groups had 500 patients each and were comparable for matched characteristics. 30 Day mortality was similar between the groups (2.4% v. 2.6% p=0.839). Deep surgical site infection (0% v. 1.6% p=0.005), urinary tract infection (5% v. 2.5% p=0.029), and operative time (275.6 min v.250 min p=0.0064) were all significantly higher in the resident participation group. Rates of other outcomes such as total length of stay, superficial surgical site infection, and sepsis were not significantly different.  In examining trends over time, overall resident participation has decreased slightly from 2005 to 2012 (p=0.0061). 30 Day mortality has remained the same over time, while operative time, LOS, and returns to the OR have all decreased over time (all with p<0.001). Resident participation was not predictive of mortality or complications; while age, ASA class, and functional status were leading predictors of both. 

Conclusion:
Despite growing time constraints and pressure to perform, surgical residents continue to perform at a high level and do not negatively affect postoperative outcomes. Residents should continue to be given active and engaging roles in the operating room, even in the most challenging cases.
 

38.10 3-Year Longitudinal Analysis of Emotional Intelligence in Surgical Residents: It Decreases Over Time

Posted on January 18, 2018

K. D. Cofer1, L. Wood1, R. Hollis1, J. Richman1, M. Morris1, J. Porterfield1, B. Lindeman1, D. Chu1  1University Of Alabama at Birmingham,Birmingham, Alabama, USA

Introduction:  Emotional intelligence (EI) is believed to be a characteristic that can change over time, however, it is unclear how it changes through the course of surgical training. In this study, we evaluated the change in EI levels of general surgery residents as they progressed over three years. We hypothesized that resident EI levels would be stable over time.

Methods:  General surgery residents at a single institution were surveyed in June of 2015 (n = 36) using the Trait EI Questionnaire (TEIQ) and June of 2016 (n = 40) and 2017 (n = 52) using the Trait EI Questionnaire-Short Form (TEIQ-SF). The TEIQ contained all items comprising the TEIQ-SF in identical format. We limited resident responses to the TEIQ-SF items to allow for identical analyses to be performed throughout all survey administrations. Residents were categorized according to their PGY level in 2015. Changes in EI were analyzed using ANOVA and t-test by PGY group for overall EI and sub-scores.

Results: A total of 16 residents completed the survey all three years. From 2015 to 2017, 13 (81%) had a decrease in overall EI, 2 residents had increased EI (13%), and a single resident had no change (6%). Overall, the mean EI score change was -0.21 (p<0.01). For sub-scores, the mean change in well-being was +0.11 (p=0.33), self-control -0.33 (p=0.03), emotionality -0.08 (p=0.63), and sociability -0.46 (p<0.01). There was no significant difference in mean baseline EI scores by PGY group, and among sub-scores, only sociability differed significantly by PGY group ranging in mean scores from 3.8 for PGY2 to 4.7 for incoming residents (p=0.01). All PGY groups had an average decline in EI, but the most significant decline occurred for the research residents (mean change -0.29, p=0.03). Of the sub-scores, the only significant change in a PGY group was a mean change of -1.1 in sociability for incoming residents (p=0.02).

Conclusion: Surgical residents’ EI levels decreased over a three-year period, driven largely by decreases in sociability and self-control. Future studies should evaluate the effects of decreased EI in surgical residents to help mitigate these potentially harmful changes.
 

39.01 Association Between ABSITE Scoring and Attrition from General Surgery Residency Training

Posted on January 18, 2018

M. M. Symer1, L. Gade3, J. Abelson1, J. A. Sosa2, H. Yeo1  1Weill Cornell Medical College,Surgery,New York, NY, USA 2Duke University Medical Center,Surgery,Durham, NC, USA 3NewYork-Presbyterian / Queens,Surgery,New York, NY, USA

Introduction: The American Board of Surgery In-Training Exam (ABSITE) has been demonstrated to predict passage of the ABS certifying exam, and is intended to guide education rather than penalize residents. Attrition from general surgery training is common and costly but poorly understood. We hypothesized that ABSITE scores would not predict attrition, but changes in score may be correlated with a resident who is struggling and at risk for impending attrition.

Methods: In 2007, all categorical general surgery interns were administered a survey during their first months of residency. De-identified survey results containing resident demographics were linked to a database of ABSITE scores assembled separately by the American Board of Surgery. Attrition was determined based on completion of training during eight years of follow-up. Residents without ABSITE scores, a matching survey, and/or missing scores were excluded. Resident ABSITE scores were analyzed based on average rank, a normalized percentile derived from their raw score. Year-to-year change in ABSITE score was used to compare residents with a significant change in performance as a possible predictor of impending attrition.

Results:Of 837 residents, 739 (88.3%) completed surveys and had continuous ABSITE data until completion or attrition from training. 108 (14.6%) did not complete training. Residents who dropped out were more likely to be female (18.7% vs 12.3% male, p = 0.02) and from programs with ≥6 residents (19.2% vs 13.0% <6 residents, p=0.04). Average ABSITE rank (median normalized percentile) was higher for participants who completed training (51.8 vs 42.7 percentile dropouts, p<0.001). Scores were also higher for residents without family nearby (53.0 vs 48.5 percentile family nearby, p<0.01). There was no difference in attrition between residents with a single ABSITE rank below the 25th percentile (12.2% vs 17.1% without a low ranking, p=0.06). Those residents who experienced an ABSITE score drop of >16.5 percentile points from the previous year were more likely to leave training (13.0% vs 6.0% without such a drop, p=0.003). In adjusted analysis, a one percentile increase in ABSITE rank was associated with decreased odds of attrition (OR 0.98 95%CI 0.97-0.99, p<0.01). 

Conclusion:Lower ABSITE scores are associated with attrition, but there is only a small absolute difference in scores between those residents who complete training and those who drop out. Program directors should focus their efforts on residents with an acute drop in scores, which may signify that a resident is at risk of impending drop out.
 

38.08 Personality Testing May Help To Identify Applicants Who Will Become High Performing Residents

Posted on January 18, 2018

R. Radhakrishnan1, D. S. Tyler1  1University Of Texas Medical Branch,Surgery,Galveston, TX, USA

Introduction:  

Identification of successful surgical residents remains a challenging endeavor for program directors (PD).  PD’s must rely on conventional application information such as standardized tests, letters of recommendation, extracurricular activities, and short, unstructured interviews to help identify applicants who will perform well in residency.  This approach has led to a national attrition rate in general surgery residencies of approximately 20% per year.

The Big 5 Personality traits (Extroversion, Agreeableness, Conscientiousness, Emotional Stability, and Openness to new ideas) and the Grit Scale have been extensively studied in many industries and have correlated with monetary and academic success in different fields.  To date, the data are lacking on the use of these tests to identify successful surgery residents. 

We hypothesized that personality testing using these two tests would provide useful additional information to identify successful surgery residents when compared with conventional application information alone.

Methods:
We performed a retrospective review of all categorical surgery residents (n=37) at the University of Texas Medical Branch from 2015-2017.  Conventional application information was scored by a single observer using our standardized scoring system which factors in all aspects of the application. Based on their performance in residency, residents were classified by the PD into two categories: low performing (ACGME milestones < 25th percentile, remediation, or leaving program, n=13) or high performing (all others, n=24).  Residents were then given personality tests.  Next, our most recent resident applicant class (n=81) was ranked in NRMP using conventional application information based on our scoring system.  During the application process, personality testing was administered to all applicants to our program.  Correlation of personality and conventional scoring to final rank position was calculated. Student’s t-test and Pearson’s correlation were used with significance set at p < 0.05. 

Results:
The Big 5 personality test identified significantly higher Extroversion, Conscientiousness, and Emotional Stability scores in high performers.  There was no significant difference in STEP, ABSITE, Grit, or applicant scores. Our final rank list appears to correlate most closely with conventional data obtained from interviews and the ERAS application.  Applicants with higher extroversion, conscientiousness, and emotional stability scores do not appear to be ranked higher using the conventional process alone.

Conclusion:
 The Big 5 test may prove to be a useful adjunct to the traditional residency application in identifying high performing residents.  Conventional interviews and ERAS application information alone may not identify potential high performing residents.

38.05 Surgical resident wellness and opportunities for improvement: A single center pilot survey

Posted on January 18, 2018

P. Marincola Smith1, P. N. Chotai1, J. L. Padgett1, S. K. Geevarghese1, K. P. Terhune1  1Vanderbilt University Medical Center,Department Of General Surgery,Nashville, TN, USA

Introduction:  

Surgical residents are at risk of burnout, depression, and poor compliance with health guidelines. We surveyed our trainees to understand their physical and mental health, and compared answers to age-appropriate health guidelines for the population at large.

Methods:  

General surgery residents at a large university-affiliated program were invited to participate in a 34-question, anonymous survey examining factors that affect physical and mental health, including self-reported work hours, compliance with age-appropriate health guidelines, and current diet and exercise habits. Validated depression (PHQ9) and fatigue (Epworth Sleepiness Scale, ESS) scales as well as questions on perceived barriers to health and wellness were included. Data was analyzed using chi-square and Mann-Whitney U tests with SPSS software. 

Results: 

Seventy-two percent of residents participated (n=55, 42% female). Most worked an average 71-80 hours per week (78%) and reported an average of 5 hours of sleep or more per night (75%). Most had at least three hours of leisure time (76.5%) or physical activity (42%), and up to one hour for religious activities (73%) or community activities (80%), per week. Lack of time was the most common (94.5%) barrier to more physical activity. Compliance with recommended primary care physician (PCP), dentist and vision visits was 25%, 23.5% and 42%, respectively. Those who saw their PCP in the last year were more satisfied with their health (p=0.049). Among female residents, 78% complied with cervical cancer screening recommendations. The majority (80%) of residents felt they did not focus enough on health. Barriers to health maintenance visits were time (80%), schedule unpredictability (76%) and appointment availability (67%). Forty-nine percent were interested in participating in work-place wellness programs, including fitness classes(56%), massages(56%), sports teams(49%), ergonomic assessments(36%) and running programs(31%). Although most (71%) reported no mental health concerns, median PHQ9 score was 5 (“mild depression”), and 11% scored in the “moderately severe” or “severe” depression category. The median ESS was 14, corresponding to moderate excessive daytime sleepiness. ESS and PHQ9 scores were positively correlated (p≤0.0001). Male and female residents scored similarly on ESS(p=0.945) and PHQ9(p=0.056) scales. Significant differences in daytime sleepiness were noted among residents in different years of training(p=0.007). Perceived mental health problems correlated with higher scores on ESS(p=0.049) and PHQ9(p≤0.0001) scales.

Conclusion: 

This single-center pilot survey identified barriers to resident wellness as well as opportunities for targeted intervention, a next intended step. Future multi-center collaborations are proposed to further promote wellness among surgical trainees. A specific target should be facilitating trainees’ abilities to meet age-appropriate health guidelines.

38.06 Surgical Resident Burnout: Does it Change Over Time?

Posted on January 18, 2018

K. D. Cofer1, L. Goss1, R. Hollis1, M. Morris1, J. Porterfield1, B. Lindeman1, D. Chu1  1University Of Alabama at Birmingham,Birmingham, Alabama, USA

Introduction:  Burnout is common among surgical residents. It is unclear what factors predict burnout and whether burnout changes over time. In this study we examined the association of burnout with emotional intelligence (EI) and performance scores as well as the changes in burnout over time. We hypothesized that resident burnout would be stable over time and associated with EI but not performance scores.

Methods:  General surgery residents at a single institution were surveyed in June of 2016 (n = 52) and 2017 (n = 58) using the Maslach Burnout Inventory (MBI) and Trait EI Questionnaire-Short Form (TEIQ-SF). Burnout was defined as scoring above pre-defined levels in at least two of the three components of burnout: emotional exhaustion (EE), depersonalization (DP), and personal accomplishment (PA). Job performance was evaluated using faculty evaluations of clinical competency-based surgical milestones and standardized test scores including the American Board of Surgery In-Training Exam (ABSITE) and the United States Medical Licensing Examination (USMLE). Statistical comparison was made using Pearson correlation and simple linear regression adjusting for PGY level. 

Results: Forty residents participated in 2016 (77%) and 10 of these residents were burned out (25%). In 2017, 52 residents participated (90%) and 12 residents were burned out (23%). Of 46 residents who received the survey in both 2016 and 2017, 26 residents (57%) participated in both years with 3 residents having burn out in both years. Changes in burnout status from 2016-2017 were not associated with changes in EI or job performance scores, including changes in ABSITE percentile. Of the 26 residents that participated in both years, 15 (58%) exhibited a change in the number of burnout components they experienced.  These changes were not associated with EI or job performance scores. Of the individual burnout components, EE was associated with marital status in 2017, with single residents experiencing higher levels of EE (p=0.01). An increase in DP scores over the year was associated with higher EI scores in 2017 (r=0.39; p=0.05). Increases in PA scores were associated with increases in EI (r=0.41; p=0.04).

Conclusion: Burnout remains prevalent in surgical residents and demonstrates change over time. Single residents reported greater levels of EE. Strategies to better predict burnout are needed as current evaluation methods may not capture the factors needed to assess a resident’s risk for development of burnout. 

 

38.04 Lack of peer and attending support increases the likelihood of burnout in general surgery residents

Posted on January 18, 2018

S. Scarlet1, M. L. Williford1, C. Goettler3, J. Green2, T. Clancy5, A. Hildreth4, D. J. Luckett1, S. Meltzer-Brody1, M. O. Meyers1, T. M. Farrell1  1University Of North Carolina At Chapel Hill,Chapel Hill, NC, USA 2Carolinas Medical Center,Charlotte, NC, USA 3East Carolina University Brody School Of Medicine,Greenville, NC, USA 4Wake Forest University School Of Medicine,Winston-Salem, NC, USA 5New Hanover Regional Medical Center,Wilmington, NC, USA

Introduction:  General surgery trainees experience high rates of burnout syndrome. Burnout syndrome has many sequelae – it increases the risk that physicians will develop serious psychiatric conditions, provide low quality health care, and commit medical errors. Burnout is associated with attrition, which is notably high amongst general surgery trainees. Although many studies have focused on the prevalence of burnout, fewer have attempted to identify risk factors. In this study, we aimed to characterize the relationship between burnout and perceived social support amongst general surgery trainees. 

Methods:  All general surgery trainees at each of the six general surgery programs in the state (n=158) were invited to complete an anonymous survey used a web-based platform. The survey was conducted between November 2016 and March 2017. The survey contained the Maslach Burnout Inventory, which is used to identify burnout syndrome, and several questions regarding social support. Descriptive statistics were calculated. Comparisons between resident responses to questions were made using Fisher’s exact or chi-squared tests, wherever appropriate. 

Results: Response rate was 58%. 75% of residents met criteria for burnout syndrome. 89% of residents agreed or strongly agreed that they had a person from whom they received support. There was no association between burnout and having a support person (p=0.672). 68% of residents agreed or strongly agreed that other residents were interested in what was going on in their lives. Perceived lack of co-resident interest in one’s life was associated with burnout syndrome – 60% of residents with burnout versus 94% of those without burnout believed that resident colleagues were interested in their lives (p=0.008). 32% of residents agreed or strongly agreed that their attendings were interested in what was going on their lives. Perceived lack of attending interest in one’s life was associated with burnout syndrome – 22% of residents with burnout versus 61% of those without burnout believed that attending colleagues were interested in their lives (p=0.004). 33% of residents agreed or strongly agreed that there were sufficient sources for addressing burnout at their institutions. Perceived institutional support was not associated with presence of burnout syndrome (p=0.574). 

Conclusion: Given its high prevalence and significant implications on patient care and provider health and well-being, interventions that prevent and treat burnout syndrome are necessary. In this study, the majority of residents felt that resources at their institutions for addressing burnout were insufficient. Residents experiencing burnout syndrome were less likely to feel that their resident colleagues and attendings were interested in their lives. These data suggest that fostering a culture of peer and attending support within residency training programs may decrease the likelihood that trainees experience burnout. 

 

38.01 Are General Surgery Residents Being Coerced to Exceed Duty Hour Limits? A FIRST Trial Analysis.

Posted on January 18, 2018

E. Blay1, K. E. Engelhardt1, B. Hewitt1, C. Quinn1, A. R. Dahlke1, A. D. Yang1, K. Y. Bilimoria1  1Northwestern University,Surgical Outcomes And Quality Improvement Center,Chicago, IL, USA

Introduction: As of July 1, 2017, the Accreditation Council for Graduate Medical Education (ACGME) has instituted duty hour limit flexibility by waiving caps on daily shift lengths, while maintaining the 80-hour-per-week cap. Importantly, residents can only stay after a 24-hour call if it is their choice to stay longer.  Our objectives were to understand how often and why residents in the Flexible Arm of the FIRST Trial were working longer than standard duty hour limits and whether this was due to coercion by attendings and senior residents or a voluntary decision made by the individual resident to stay longer.

Methods: All clinical General Surgery residents taking the 2017 American Board of Surgery In-Training Examination (ABSITE) were surveyed. This analysis was limited to residents in the Flexible Arm of the FIRST Trial. The main outcome was number of times the resident exceeded 2011 duty hour limits in a typical month dichotomized into 0 or ≥ 1 event.  If residents indicated that their duty hours exceeded limits in a typical month, they were asked additional questions about duty hour expectations and coercion on a 5-point Likert scale from “Strongly Agree” to “Strongly Disagree.” Rates were compared and regression models were developed to (1) identify resident and program factors associated with exceeding standard duty hour limits and (2) identify predictors of coercion to stay longer.

Results: In the Flexible Arm of the FIRST trial, 1838/1838 (100%) of clinical residents in 58 programs responded to the survey. Of 68% (n=1258) residents who exceeded duty hour rules, 22% (n= 273) of residents said their programs expected them to stay longer than standard duty hour limits.  When residents stayed longer than standard duty hour limits, 78% (n= 983) responded that they voluntarily stayed longer, while 7% (n=93) reported coercion from attendings and 9% (n=117) reported coercion from senior residents. Although females (OR 1.89, 95% CI [1.52-2.34]), interns (OR 4.47, 95% CI [3.32-6.03]) and junior residents (OR 1.43, 95% CI [1.14-1.81]) were more likely to report exceeding standard duty hour limits, there were no significant resident or program characteristics associated with coercion by attendings or senior residents to exceed duty hour limits.

Conclusion: When duty hour flexibility was utilized in the Flexible Arm of the FIRST Trial, it was generally due to the residents choosing to stay voluntarily; however, there was some coercion by attendings and senior residents. As duty hour rules transition into an era of flexibility, programs should be cognizant of ensuring residents are staying for clinical and educational purposes of their own accord and are not being coerced to break ACGME duty hour regulations unnecessarily.

 

38.02 Gender Differences in Residency: Duty Hour Utilization, Burnout and Psychological Wellbeing

Posted on January 18, 2018

A. R. Dahlke1, J. K. Johnson1,3, C. C. Greenberg4, R. Love1, L. Kreutzer1, D. B. Hewitt1,5, C. M. Quinn1, K. Engelhardt1,6, K. Y. Bilimoria1,2  1Northwestern University- Feinberg School Of Medicine, Surgical Outcomes And Quality Improvement Center (SOQIC),Department Of Surgery,Chicago, IL, USA 2American College Of Surgeons,Chicago, IL, USA 3Northwestern University-Feinberg School Of Medicine,Center For Healthcare Studies In The Institute For Public Health And Medicine,Chicago, IL, USA 4Wisconsin Surgical Outcomes Research (WiSOR) Program,Department Of Surgery,Madison, WI, USA 5Thomas Jefferson University Hospital,Department Of Surgery,Philadelphia, PA, USA 6Medical University Of South Carolina,Department Of Surgery,Charleston, SC, USA

Introduction: As the number of women in surgical residency programs continues to increase, there is a growing recognition that women and men may enter, experience, and even leave residency programs differently. Recent studies have shown that up to 65% of surgical residents experience some amount of burnout and challenges to their wellbeing. Our objective is to (1) assess differences in how male and female general surgery residents utilize duty hour regulations and experience burnout and psychological wellbeing and (2) examine reasons why women and men may have differing experiences with duty hours, aspects of burnout, and issues with psychological wellbeing.

Methods: 7,395 surgical residents completed a survey (99% response rate) regarding how often and why they exceeded 2011 standard duty hour limits, as well as about aspects of burnout and psychological wellbeing. Hierarchical logistic regression models were developed to examine the association between gender and each of the resident outcomes. 98 semi-structured interviews were completed with 42 faculty and 56 residents. Transcripts were analyzed thematically using a constant comparative approach. 

Results: Female residents reported more frequently staying in the hospital >28 hours or violating the 80 hour work week maximum ≥3 times in a month, as well as more frequently feeling fatigued and burned out from their work (P<0.001). Females also reported less frequently treating patients as “impersonal objects” or “not caring” what happens to patients (P<0.001). Women reported more often: losing sleep due to worry, being unable to make decisions, feeling constantly under strain, being unable to overcome difficulties, feeling unhappy or depressed, feeling a loss of self-confidence, or thinking of themselves as worthless (P<0.01). In adjusted analyses, all associations remained significant. Themes identified in the qualitative analysis as possible contributory factors to gender differences in residency include: lack of mentorship/leadership roles by women surgeons, dual role responsibilities (surgeon and family), the inability of co-workers to understand gender differences (gender blindness), and gender-based differences regarding pressures and challenges, as well as in approaches to patient care.

Conclusion: Our study found that women report working extended shifts more often than men and experience worse contributing factors to burnout and poor psychological wellbeing. This mixed-methods study adds to the existing literature on resident wellbeing, and calls for a closer look into how gender schemas drive the differences in the way male and female surgeons work, behave, and ultimately cope during residency. Focusing future research on the differences in how women and men navigate residency and their social, emotional, and mentoring needs may help us develop policy recommendations as well as specific programmatic or cultural interventions.

 

36.04 Surgical Procedures in Health Professional Shortage Areas: Impact of a Surgeon Incentive Payment Plan

Posted on January 18, 2018

A. Diaz1, E. Schneider1, J. Cloyd1, T. M. Pawlik1  1Ohio State University,Columbus, OH, USA

Introduction:  The American College of Surgeons has predicted a physician shortage in the US with a particular deficiency in general surgeons. Any shortage in surgical workforce is likely to impact underserved areas. The Affordable Care Act (ACA) established a Center for Medicare/Medicaid Services (CMS) based 10% reimbursement bonus for general surgeons in Health Professional Shortage Areas (HPSAs). We sought to assess the impact of the ACA Surgery Incentive Payment (SIP) on surgical procedures performed in HPSAs.

Methods:  Hospital utilization data from the California Office of Statewide Health Planning and Development between January 1, 2006 and December 31, 2015 were used to categorize hospitals according to HPSA location.  A difference in difference analysis was used to measure the effect of the SIP on year-to-year differences for in- and out-patient surgical procedures by hospital type pre-(2006-2010) versus post-(2011-2015) SIP implementation.

Results: Among 409 hospitals, two hospitals performed surgery in a designated HPSA. Both HPSA hospitals were located in a rural area, were non-teaching, and had <500 beds. The number of total surgical procedures was similar at both non-HPSA (Pre: n=210, 6,048  vs. Post: n=212,1,550) and HPSA (Pre: n=8,734  vs. Post: n=8,776) hospitals. Over the time period examined, inpatient (IP) procedures decreased (non-HPSA, Pre: 933,388 vs. Post: 890,322; HPSA, Pre: 5,166 vs. Post: 4,301), while outpatient (OP) procedures increased (non-HPSA, Pre: 1,172,660 vs. Post: 1,231,228; HPSA, Pre: 3,568 vs. Post: 4,475)(all p< 0.05). Post-SIP implementation, surgical procedures performed at HPSA hospitals markedly increased compared with non-HPSA hospitals (IP non-HPSA: -625 vs. HPSA: 363; OP non-HPSA: -111 vs. HPSA: 482)(both p<0.05). Of note, while the number of ORs increased over time among non-HPSA hospitals (Pre: n=3,042 vs. Post: n=3,206, p<0.05) OR numbers remained stable at HPSA hospitals (Pre: n=16 vs. Post: n=17). To estimate population-level effects of the SIP, a difference-in-differences model was used to adjust for cluster-related changes, as well as preexisting differences among non-HPSA and HPSA hospitals. Using this approach, the impact of the SIP on surgical procedure volume among HPSA relative to non-HPSA hospitals was noted to be considerable (Figure 1). 

Conclusion:  CMS SIP implementation was associated with a significant increase in the number of surgical procedures performed at HPSA hospitals relative to non-HPSA hospitals, essentially reversing the trend from negative to positive. Further analyses are warranted to determine whether bonus payment policies actually help to fill a need in underserved areas or whether incentives simply shift procedures from non-HPSA to HPSA hospitals.

35.09 The Significance of Laparoscopic Bursectomy Via an Outside Bursa Omentalis Approach in Gastric Cancer

Posted on January 18, 2018

L. Zou1, B. Zheng1, L. Zou1  1Guangdong Provincial Hospital Of Chinese Medicine,Department Of Gastrointestinal Surgery,Guangzhou, GUANGDONG, China

Introduction:

This study was aimed to compare the safety, feasibility and short-term effects of Laparoscopic bursectomy and D2 radical gastrectomy(LBDRG) with those of laparoscopic D2 radical gastrectomy (LDRG) in advanced gastric cancer (AGC).

Methods:

We retrospectively analyzed data on 68 consecutive patients undergoing LBDRG via an outside bursa omentalis approach (OBOA) from August 2012 to December 2014. The surgical outcomes of patients who underwent LBDRG were matched and compared with those of patients who underwent classic LDRG in our department at the same time.

Results:

The clinicopathological characteristics were similar between the two groups following matching. Although the mean operative time was longer in the LBDRG group than in the LDRG group (323.4±20.70 min vs. 288.5±21.76 min; p<0.05), the number of lymph nodes dissected was significantly greater in the LBDRG group than in the LDRG group (30.49±5.41 vs. 23.2±4.87; p<0.05). Additionally, there was no significant difference in the rate of local recurrence or metastases within the median two-year follow-up between the LBDRG group (5.9% [4/68]) and the LDRG group (8.8% [6/68]). 

Conclusion:
These results suggested that this technique is technically safe and feasible for AGC patients, and the short-term oncological effects are equal to those of LDRG.
 

33.10 Medical Optimization Prior to Surgery Improves Outcomes but is Underutilized

Posted on January 18, 2018

I. L. Leeds1, J. K. Canner1, F. Gani1, P. M. Meyers1, E. R. Haut1, J. E. Efron1, F. M. Johnston1  1Johns Hopkins University School Of Medicine,Department Of Surgery,Baltimore, MD, USA

Introduction:  Preoperative comorbidities can have substantial effects on operative risk and outcomes. The modifiability of these risks remains poorly understood. The purpose of this study was to evaluate the impact of non-surgeon preoperative comorbidity optimization on short-term postoperative outcomes.

Methods: Patients with employer-sponsored commercial insurance undergoing a colectomy (ICD-9 codes: 17.3x, 45.7x, 45.8x, 48.5) were identified in the Truven Health MarketScan database (2010-2014). Patients were included if they could be matched to a preoperative surgical clinic visit within 90 days of an operative intervention by the same surgeon. The time interval between the surgical visit and the colectomy was defined as the “potential preoperative optimization period.” In this time interval, patients were defined as “optimized” if they were seen by an appropriate non-surgeon for at least one of their preexisting comorbidities (e.g., primary care or endocrinology visit for diabetic patient). Propensity score matching with 1:1 nearest-neighbor matching with replacement was performed prior to regression analysis to account for between-group covariate extremes. Bivariate analysis and mult

Results: We identified 16,279 eligible colectomy episodes, of which 3,940 (24.2%) were in patients with at least one clinically significant comorbidity. 64.8% of patients with comorbidities were medically optimized prior to surgery. 2,545 medical optimized patients were matched to 1,388 non-optimized controls. Operative indications included neoplasm (50.5%) and diverticulitis (32.6%). The optimized subgroup was significantly older, more likely to be male, more comorbid at baseline by Charlson score, and more likely to reside in the northeastern United States.

 

Medically optimized patients had a lower risk of complications (29.9% vs. 33.7%, p=0.014) driven largely by fewer postoperative gastrointestinal, renal, hepatic, wound, and septic complications. Multivariable logistic regression controlling for patient demographics, operative indication, and Charlson Comorbidity Index demonstrated that patients optimized prior to surgery had a 15% lower odds (OR 95% CI = 0.73-0.99, p=0.036) of having a complication compared with non-optimized patients. The median increase in preoperative costs for optimized patients was $1,519 (p<0.001) while the median increased total cost with a complication was $18,941 (p<0.001).

Conclusion: Many surgical patients do not receive focused preoperative care for their medical comorbidities. Patients who receive comorbidity-associated nonsurgical care prior to an operation have better short-term surgical outcomes. The individual costs of medical optimization are much less than the cost of a surgical complication. These findings support further prospective study of whether patients undergoing high-risk surgery can benefit from more intensive preoperative optimization.

33.09 Laparoscopic Cholecystectomy Is Safe Both Day and Night

Posted on January 18, 2018

E. S. Tseng1, J. Imran1, J. Byrd1, I. Nassour1, S. S. Luk1, M. Choti1, M. Cripps1  1University Of Texas Southwestern Medical Center,Dallas, TX, USA

Introduction: The acute care surgical model has increased the ability to perform non-elective laparoscopic cholecystectomies (LC) during day and night hours. Despite the potential to reduce hospital length of stay (LOS) and improve operating room usage, it is reported that performing LC at night leads to increased rates of complications and conversion to open. We hypothesize that it is safe to perform LC at night in appropriately selected patients.

Methods:  We performed a retrospective review of over 5200 non-elective LC in adults at a large urban tertiary referral hospital performed between April 2007 and February 2015. We dichotomized the cases to either day (case started between 7am-6:59pm) or night (case started between 7pm-6:59am). Univariate analysis was performed using Mann-Whitney U, chi-squared, and Fisher's exact tests.

Results: A total of 5206 patients underwent LC, with 4628 during the day and 576 at night. There was no difference in age; body mass index (BMI); ASA class; race; insurance type; pregnancy rate; history of hypertension, diabetes, or renal failure; or white blood cell count. However, patients who underwent LC during the day were more likely to have presented with obstructive biliary complications of cholelithiasis as evidenced by higher median total bilirubin (0.6 [0.4, 1.3] vs. 0.5 [0.3, 1.0] mg/dL, p = 0.002) and lipase (33 [24, 56] vs. 30 [22, 42] U/L, p < 0.001). Operatively, there was no difference in case length, estimated blood loss, rate of conversion to open, biliary complications, LOS after operation, unanticipated return to the hospital in 60 days, or 60-day mortality. There were significant differences in median LOS before surgery (1 [1, 2] vs. 1 [0, 2] days, p < 0.001) and median total LOS (3 [2, 4] vs. 2 [1, 3] days, p < 0.001) with day patients spending more time in the hospital compared to night patients. Logistic regression to look at the effects of ASA class, total bilirubin, lipase, BMI, and day vs. night status on the likelihood of biliary complications showed that none of the factors had statistical significance.

Conclusion: In this center with an acute care surgery service, it is safe to perform LC during day or night. The lack of complications and shorter LOS justifies performing LC at any hour.

 

33.07 Characterizing Surgeon Prescribing Practices and Opioid Use after Outpatient General Surgery

Posted on January 18, 2018

J. R. Imbus1, J. L. Philip1, J. S. Danobeitia1, D. F. Schneider1, D. Melnick1  1University Of Wisconsin,Surgery,Madison, WI, USA

Introduction: Surgeons typically prescribe opioids for patients undergoing outpatient general surgery operations, yet opioid prescribing practices are not standardized. Excess opioid supply in the community leads to abuse and diversion. Identifying patient and operative characteristics associated with postoperative opioid use could reduce overprescribing, and optimize prescribed quantity to patient need. Our aim was to characterize prescribing practices and opioid use after common outpatient general surgery operations, and to investigate predictors of opioid amount used.

Methods: We developed a postoperative pain questionnaire for adult patients undergoing outpatient inguinal hernia repair (IHR), laparoscopic cholecystectomy (LC), breast lumpectomy +/- sentinel lymph node biopsy, and umbilical hernia repair (UHR) at our institution. This facilitated a retrospective review of patients undergoing operations from January to May 2017, excluding those with postoperative complications. We collected opioid prescription data, operative details, and patient characteristics. All opioids were standardized to morphine milligram equivalents (MME) and reported as a corresponding number of 5mg hydrocodone pills for interpretability. Multivariable linear regression was used to investigate factors associated with opioid use.

Results: The 374 eligible cases included 114 (30.6%) unilateral and 59 (15.8%) bilateral IHRs, 90 (24%) LCs, 17 (4.6%) lumpectomies, 33 (8.9%) lumpectomies with sentinel node biopsy, and 60 (16.1%) UHRs. Forty-eight providers prescribed six different opioids. There was variation in prescribed quantity for all procedures, ranging from zero to 80 pills. Median numbers of pills prescribed vs taken were 20 vs 5.5 for unilateral IHR, 20 vs 4 for bilateral IHR, 20 vs 10 for LC, 10 vs 1 for lumpectomy, 20 vs 2 for lumpectomy with sentinel node biopsy, and 20 vs 5 for UHR. Most patients (86%) were over-prescribed. Nearly all (95%) patients took 30 or fewer pills. Twenty-four percent of patients took zero pills.

Univariate analysis showed operation type (p<.001), age (p<.001), body mass index (p<0.01), chronic pain history (p<0.01), and pre-operative opioid use (p<0.01) to be associated with MME amount taken. On multivariable analysis, there was a significant relationship between opioid use and age (p<0.001), with 16-34% less MME taken for every ten year age increase. Patients who underwent LC took over twice as much opioids compared to patients undergoing UHR (p<0.05). Opioid amount taken was independently associated with opioid amount prescribed (p<0.001), with patients taking 24% more MME for every additional ten pills prescribed.

Conclusion: Marked variation exists in opioid type and amount prescribed, and most patients receive more opioids than they consume. Higher prescription amounts contribute to more opioid use, and certain patient subsets may be more (LC) or less (elderly) likely to use opioids postoperatively.

30.09 The Economics of Private Practice Versus Academia in Surgery: an Analysis of Sub-Specialization.

Posted on January 18, 2018

M. Baimas-George1, B. Fleischer1, J. R. Korndorffer1, D. Slakey1, C. DuCoin1  1Tulane University School Of Medicine,Surgery,New Orleans, LA, USA

Introduction:  In the surgical field, residents often make career decisions regarding future practice without adequate knowledge or exposure to the realities of professional life, particularly private practice. Currently there is a paucity of comparable data regarding the economic differences between practice models.  This study seeks to illuminate the financial disparities of surgical sub-specialties between academic and private surgical practice.

Methods:  Data was collected from the Association of American Medical College (AAMC) and the Medical Group Management Association’s (MGMA) 2015 reports of average annual salaries. Salaries were analyzed for eight comparative surgical sub-specializations, and regional data was combined for a national average. Fixed time of practice was set at 30 years. Assumptions for the calculation of lifetime revenue in academia included 5 years as assistant professor, 10 years as associate professor, and 15 years as full professor. The formula utilized is as follows: (average yearly salary) x [years of practice (30 yrs – fellowship/research yrs)] + ($50,000 x yrs of fellowship/research) = total adjusted lifetime revenue.

Results: As a full professor, academic surgeons in all sub-specialties make significantly less than their private practice counterparts. The largest discrepancy is in vascular and cardiothoracic surgery, with full professors earning 16% and 14% less than private practitioners respectively. Plastic surgery and general surgery are the only two disciplines that have similar lifetime revenues to private practitioners, earning only 2% and 6% less than their counterparts’ lifetime revenue respectively.  Surgical oncology is the only sub-specialty that regardless of practice model (academic vs private) or academic status (assistant, associate, or professor) grossed less lifetime revenue than general surgery.

Conclusion: Academic surgeons in all surgical sub-specialties examined earn less lifetime revenue compared to those in private practice.  This difference in earnings decreases but remains substantial as an academic surgeon advances from assistant to associate to full professor.  With limited exposure to the diversity of possible professional arenas, residents must be aware of this considerable discrepancy. 
 

30.10 Unnecessary Use of Plain Abdominal Radiographs in Patients of Acute Abdomen

Posted on January 18, 2018

D. Soares1, K. M. Pal1  1Aga Khan University Medical College,Surgery,Karachi, Sindh, Pakistan

Introduction:
Acute abdomen accounts for 5-10% of visits to the ER. An early and accurate diagnosis is essential in the management of these patients. Usually the first radiological investigation performed is an abdominal X-ray. However in most cases an abdominal X-ray is unable to reach a diagnosis and the patient then has to undergo further investigations. In our study, we wished to establish in how many patients presenting to the ER with acute abdominal pain was an abdominal X-ray done unnecessarily and did not lead to a final diagnosis. 

Methods:
This was a cross-sectional study conducted at the Department of Surgery at Aga Khan University Hospital over a 6 month period from April to October 2016. Patients aged 16 to 60 years of any gender, who presented to the ER with non-traumatic abdominal pain, lasting more than 2 hours and less than 5 days in duration, and which measured more than 5 on the VAS were included in the study. The patients who presented with acute abdomen and undergoing an abdominal X-ray were followed. The principal investigator then reviewed how helpful the X-ray was in the diagnosis, and calculated the proportion of X-rays that were done unnecessarily. Data was analysed using SPSS version 19. 

Results:

A total of 110 patients were included in the study.

The initial diagnosis was intestinal obstruction in 47.3% (n=52), followed by acute pancreatitis in 15.5% (n=17), peritonitis in 9.1% (n=10), constipation in 8.2% (n=9), acute cholecysitis 5.5% (n=6) and acute appendicitis in 4.5% (n=5). 

The x-ray findings included a non-specific bowel gas pattern in 50% (n= 55). Significant findings included dilated small bowel loops in 23.6% (n=26) and fecal loading in 19.1% (n=21); air fluid levels, calcific opacity in the right lumbar region, dilated large bowel loops in 1.8% respectively; and diffuse haziness in the abdomen and a foreign body in 1 patient respectively.

The most common final diagnoses were intestinal obstruction (27.3%), acute pancreatitis (14.5%) and constipation (10%). 

The proportion of unnecessary X-rays was found to be 69.1% (n=76) with only 30.9% (n=34) actually leading to a final diagnosis.

We stratified different variables on the basis of the necessity of the x-ray. The location of pain (p = 0.007), the x-ray findings (p = 0.000) and the final diagnosis (p = 0.000) was found to be significantly associated with the unnecessary use of x-rays. Abdominal x-ray was found to have some usefulness in intestinal obstruction, ureteric caluclus, foreign body and constipation in geriatric patients. It was also found that the visual analog scale had a significant association with the use of unnecessary x-rays. On further analysis, it was found that patients with a VAS of 8 and above were more likely to have an unnecessary x-ray as opposed to patients with a VAS of 6-7. 

Conclusion:

The abdominal X-ray for acute abdomen was done unnecessarily in 69% of the patients presenting with acute abdomen.

30.08 Functional Status vs. Frailty in GI Surgery: Are They Comparable in Predicting Short Term Outcomes?

Posted on January 18, 2018

S. Y. Chen1, M. Stem1, S. L. Gearhart1, B. Safar1, S. H. Fang1, J. E. Efron1  1Johns Hopkins University School Of Medicine,Department Of Surgery,Baltimore, MD, USA

Introduction:
Functional dependence and frailty are important factors in assessing preoperative risk. No studies to date have compared functional dependence with frailty as predictors of surgical outcomes. We sought to compare the impact of functional dependence and frailty on early outcomes after gastrointestinal (GI) surgery, including readmission.

Methods:
Patients who underwent GI surgery were identified using the ACS-NSQIP database (2012-2015). Functional dependence is defined by NSQIP as “partial or total assistance with performing activities of daily living (bathing, feeding, dressing, toileting, and mobility) in the 30 days prior to surgery.” The 5-item modified frailty index (mFI) consists of: history of severe chronic obstructive pulmonary disease, congestive heart failure, functional status, hypertension requiring medication, and diabetes. Propensity score matching analysis was used to separately match dependent and independent patients, and patients with mFI<3 and mFI≥3 on baseline characteristics. Multivariable logistic regression analysis was utilized. Postoperative outcomes and reasons for readmission were compared. A subgroup analysis of colectomy patients was also performed.

Results:
Of 765,082 patients, 1.71% were dependent, and 1.49% had mFI≥3. Similar outcomes were observed in matched cohorts for dependent and mFI≥3 patients: readmission (15.61% dependent; 5.75% mFI≥3), overall morbidity (37.91%; 34.81%), serious morbidity (19.06%; 17.06%), mortality (6.73%; 5.43%), and reoperation (7.01%; 6.48%). Dependent and mFI≥3 patients had similar and increased odds of outcomes on adjusted multivariable logistic analysis (TABLE) and shared three of the top five indicators for readmission: complication of surgical procedure (11.46% dependent; 11.23% mFI≥3), intestinal obstruction (10.70%; 7.65%), and organ space surgical site infection (7.93%; 8.65%). Comparable outcomes and reasons for readmission were also obtained for dependent and mFI≥ 3 colectomy patients: overall morbidity (51.14% dependent; 49.03% mFI≥ 3), serious morbidity (25.12%; 23.11%), mortality (8.83%; 8.08%), reoperation (8.60%; 7.98%), and readmission (17.79%; 17.75%) Colectomy patients shared four of the top five reasons for readmission: 1) intestinal obstruction without hernia (13.06% dependent; 9.06% mFI≥ 3 ), 2)  complications of surgical procedure (9.44%; 10.40%), 3) organ/space SSI (8.06%; 9.40%), and 4) respiratory complications (6.94%; 8.39%).

Conclusion:
Functional dependence and frailty are comparable in predicting outcomes including readmission after GI surgery. Functional dependence should be considered an acceptable and practical alternative for preoperative risk stratification in a clinical setting.
 

30.07 M&M Combined with Critique Algorithm-Based Database Reliably Evaluates Quality of Surgical Care

Posted on January 18, 2018

A. C. Antonacci1, S. Dechario1, J. Nicastro1, G. Coppa1, C. Antonacci2, M. Jarrett1  1North Shore University And Long Island Jewish Medical Center,Surgery,Manhasset, NY, USA 2Tulane University School Of Medicine,New Orleans, LA, USA

Introduction:

Collection and critique of actuarial complication data following surgery has been a historically difficult endeavor. Weekly Morbidity and Mortality conference (MMC) review combined with a standardized critique algorithm as part of a relational database can provide valuable cumulative data useful for evaluation of surgical quality.

 

Methods:

From January 2014 to July 2017,  62,377 general surgery operative procedures were performed at two major university based medical centers within our health system. We collected weekly Morbidity/Mortality reports from a total of 741 cases comprising 1714 adverse events (2.75% complication rate) and 194 deaths (0.31% mortality rate).  Approximately 250 cases were presented in detail at MMC. However, all cases were analyzed for adverse event incidence, Clavien-Dindo risk profile, error assessment (i.e., diagnostic, judgment, technical, communication and system), management and high-risk surgery.  Management evaluation was  determined by a small group of senior surgeons not involved with individual cases. Reports were reviewed at the department and provider level, and used to guide quality improvement processes.    

Results: 

The overall mortality rate for the study group was 0.31%. Yet,  the mortality rate for patients sustaining an adverse event was 25.9% (194/741), or 11.3% (194/1714) of adverse events.  Patients without mortality sustained an average of 1.7 complications per case and patients who expired sustained an average of 2.84 complications per case. There were no statistically significant differences in the management of survivors vs. non-surviviors.  Returns to the operating room (RTOR), death, intrabdominal abcess, return to interventional suite (RTIS), and hemorrhage requiring transfusion were the most common adverse events reported overall.  Technical (60%), judgment (20.1%), system (13.1%) and diagnostic (6%) errors occurred with equal frequency between both campuses. Denominator adjusted complication and mortality rates in high-risk surgical procedures  ranged from 6.5% to 23.5%, and as high as 2.8%, respectively. Over eighty-five percent (85%)  of  reported cases had Clavien Dindo scores between Grade IIIa and Grade V, confirming that  post-operative RTIS, RTOR, ICU care for systemic disease and death were important features of the complication profile.

 

Conclusion:

 Denominator adjusted morbidity and mortality rates are elevated well beyond reported overall rates. The number of complications following surgery are statistically associated with mortality, and  patients who sustain a complication  have an eleven percent (11%) risk of death. This methodology has implications not only for focused quality improvement, but for teaching a logical approach to self-assessment in the context of residency training. This project describes the feasibility of combining MMC  with a standardized critique algorithm-based database to provide accurate risk-adjusted data useful for comprehensive assessment of  surgical quality.

 

 

30.04 Geriatric Syndromes Predict the Timing of Early Postoperative Do-Not-Resuscitate (DNR) Orders

Posted on January 18, 2018

M. A. Hornor1,2, R. A. Rosenthal1,3,5, T. N. Robinson1,4,6  1American College Of Surgeons,Chicago, IL, USA 2Ohio State University Wexner Medical Center,Department Of Surgery,Columbus, OH, USA 3Yale University School Of Medicine,Department Of Surgery,New Haven, CT, USA 4University Of Colorado Anschutz Medical Campus,Department Of Surgery,Aurora, CO, USA 5Veterans Affairs Connecticut Health Care System,New Haven, CONNECTICUT, USA 6Veterans Affairs Eastern Colorado Health Care System,Aurora, COLORADO, USA

Introduction:  The timing of and risk factors for new DNR orders following surgery in older adults are not well defined. The goal of this study was to investigate the timing of new postoperative DNR orders and to determine if identifiable geriatric syndromes are associated with early postoperative DNR.

Methods:  We performed a retrospective cohort study using data from the American College of Surgeons’ (ACS) National Surgical Quality Improvement Project (NSQIP) Geriatric Surgery Pilot Project that collects an additional 20 geriatric and palliative care-specific variables at 26 hospitals.  Patients aged ≥ 65 who underwent an inpatient operation were included. The timing of postoperative DNR orders was determined and univariate and multivariate analyses were performed to examine the association between patient factors and early postoperative DNR orders, defined as a new DNR order placed on postoperative day 0-2.

Results: Of the 29,864 patients included in the study, 717 (2.4%) patients had a DNR order placed postoperatively, 329 (1.1%) of which were classified as early. Over half of the patients with early postoperative DNR’s underwent emergency surgery (58.1%). In the adjusted multivariate model, preoperatively identifiable geriatric syndromes were significantly associated with early postoperative DNR [Table 1].  

Conclusion: Early postoperative DNR orders are highly associated with preoperative geriatric syndromes and emergency operation status. The consideration of geriatric syndromes such as cognitive and functional status in shared decision making conversations prior to surgery may better inform advance care planning and surgical decision making. 

 

30.05 Influence of English Proficiency on Patient Provider Communication and Shared Decision Making

Posted on January 18, 2018

A. Z. Paredes1, J. Idrees1, E. W. Beal1, Q. Chen1, E. Cerier1, V. Okunrintemi1, G. Olsen1, S. Sun1, T. M. Pawlik1  1Ohio State University,General Surgery,Columbus, OH, USA

Introduction: The proportion of Hispanic and Asian persons in the United States is expected to increase over the next 50 years. In turn, the number of patients who speak a language other than English will also continue to increase. The effect of English proficiency on health care outcomes has been poorly studied, yet may be important. Therefore, we sought to define the impact of English proficiency on self-reported patient provider communication and shared decision-making.

Methods: The 2013-2014 Medical Expenditure Panel Survey database was utilized to identify respondents who spoke a language other than English and who had self-rated their proficiency in English. Patient provider communication (PPC) and Shared Decision Making (SDM) were characterized into three categories using a composite score that ranged from 4 to 12 (score 4-7: “poor," 8-11: “average,” and 12 “optimal”). The relationship between PPC, SDM and English proficiency was analyzed using regression analysis.

Results: 13,880 respondents spoke a language other than English and self-rated their English proficiency. Most respondents were white (n=10,281, 75%), age 18-39 years (n=6,677, 48%), male (n=7,275, 52%), middle income (n=4,125, 30%), born outside of the United States (n=9,125, 65%), and currently lived in the Western region of the United States (n=5,812, 42%). English proficiency was rated as “very well” (n=7,221, 52%), “well” (n=2,378, 17%), “not well” (n=2,820, 20%) or “not at all” (n=1,463, 10%). Among individuals who self-reported English proficiency as “not at all,” 81% had the medical interview conducted completely in the patient’s native language with or without the use of translator (“well” 38% vs. “not well” 72%  p=<0.001). On multivariable analysis, compared with “very well,” patients who self-reported English proficiency as “well” (OR 1.21, CI 1.033–1.42) or “not well” (OR 1.21, CI 1.04–1.43) were more likely to report "poor" PPC (both p<0.02). Similarly, SDM was more commonly self reported as “poor” among patients who reported English proficiency as “not well” (OR 1.31, CI 1.04–1.65, p=0.02). Compared with patients with “very well” English proficiency, individuals who reported “not at all” English proficiency had comparable PPC (OR 1.0, CI 0.82–1.23) and SDM (OR 0.96, CI 0.72–1.28) scores (p>0.05, both). Of note, the majority of patients who reported “poor” PPC had self-reported their proficiency as “well” and therefore had their interview conducted in English (n=413, 72%).

Conclusion: Decreased English proficiency was associated with worse self-reported PPC and SDM. Among patients for whom English was a second language, PPC was “poor” even among patients who reported English proficiency as “well” when the interview was conducted in English. Attention to the patient language needs is critical to patient satisfaction.

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