3.02 Intestinal Alkaline Phosphatase Deficiency Confers Susceptibility to T1DM in STZ Mouse Model

Posted on January 18, 2018

R. Vasan1, F. Kuehn1, J. Ramirez1, F. Adiliaghdam1, E. Liu1, Y. Liu1, M. Farber1, R. Pepen1, C. Freguia2, M. Kaleko2, R. A. Hodin1  1Massachusetts General Hospital,General Surgery,Boston, MA, USA 2Synthetic Biologics,Rockville, MD, USA

Introduction:

Intestinal alkaline phosphatase (IAP) maintains intestinal barrier integrity, prevents translocation of bacterially-derived products into the bloodstream, and diminishes low-grade systemic inflammation thought to contribute to diabetes mellitus pathogenesis. We have recently described the expression of IAP within pancreatic islets themselves. We aimed to determine resilience of IAP-KO animals to β-cell damage.

Methods:

A 5-day low-dose 40mg/kg/day, intraperitoneal streptozotocin (STZ) injection protocol was utilized as a model of T1DM β-cell damage. 12-week-old C57BL/6J Wild Type and IAP-KO mice received i.p. STZ or vehicle (4 groups, n=5). Study duration was 5 weeks. Measurements included periodic blood glucose, weekly food intake and weights, and daily water intake. Serum insulin and c-peptide were measured at sacrifice. Pancreatic islets were harvested for histology and insulin staining.

Results:

Blood glucose was significantly increased at 5 weeks in IAP-KO mice injected with STZ compared to their WT counterparts (554.2+/-37.2 vs. 296.4+/-11.6 mg/dL, p<0.01), as was food (47.8 vs. 23.5 g/week, p<0.05) and water intake (14.2 vs. 5.8ml/day, p<0.01). Serum insulin and c-peptide levels were markedly reduced – (21.1 vs. 75.4 µU/ml, p<0.01) and (0.43 vs. 1.22 ng/ml, p<0.01) respectively.

Conclusion:

IAP-KO mice in this study were more susceptible to STZ-induced β-cell damage and developed significantly worse diabetes compared to their WT counterparts. These results suggest that in addition to its well-recognized role in promoting gut barrier function, IAP may also serve a protective function within the pancreatic islets.

3.03 Notch is Protective in Spleen Against Apoptosis During Endotoxemia via TLR4/Myd88/iNOS/TACE Pathway

Posted on January 18, 2018

C. Yang1,2, M. Deng2, M. Scott2, T. Billiar2  1Tsinghua University,Medical School,Beijing, BEIJING, China 2University Of Pittsburg,Pittsburgh, PA, USA

Introduction:
Notch is a highly conserved transmembrane receptor well-known to regulate cell to cell communication as well as cell fate decisions. In recent years, Notch signaling has been implicated in inflammation, yet the regulation and roles of Notch in sepsis are unknown. The sheddase, TNFα-converting enzyme (TACE/ADAM17) participates in cleavage and activation of Notch and we have previously shown that TACE is activated via the TLR4-MyD88-iNOS-NO pathway in hepatocytes during endotoxemia. Thus, we hypothesized that Notch signaling pathway is regulated by TLR4/Myd88/iNOS/NO/TACE pathway in spleen during endotoxemia.

Methods:
To test our hypothesis, WT (C57BL/6), Myd88-/-, TLR4-/-, iNOS-/-mice were injected saline or 5mg/kg LPS i.p, spleen and serum were harvested 8 hours after injection. In vitro, primary mice splenocytes were exposed to LPS and treated with or without iNOS inhibitors and NO donors. Activation of Notch and cell death in splenocytes was assessed.

Results:
The Notch signaling pathway was activated in the spleen and in splenocytes after LPS challenge in a time-dependent manner, indicated by increased cleaved intracellular notch measure as notch intracellular domain (NICD) by western. The NICD levels peaked at 8 hours and 4 hours after LPS in the spleen and in the splenocytes, respectively. Inhibition of Notch activation using DAPT (5 mg/kg), 3 hours prior to LPS injection, resulted in a significantly increased level of cleaved-caspase-3, indicating more apoptosis in the absence of Notch signaling. LPS-induced Notch activation was significantly lower in Myd88-/- mice and  TLR4-/- mice as well as iNOS-/- after LPS challenge and this we associated with increased levels of cleaved-caspase3. Similar results were also obtained in vitro in splenocytes treated with an iNOS inhibitor 1400w (2 uM). Moreover, Notch activation was induced in splenocytes by using SNAP (200 uM) as an NO donor or directly by the cGMP analog 8-pCPT-cGMP(400 uM). Inhibition of TACE with TAPI-II (800 nM) greatly reduced LPS-induced Notch activation in splenocytes and resulting in increased cleaved-caspase3. 

Conclusion:
Our data suggests that Notch signaling pathway is activated during endotoxemia under the regulation of iNOS/NO and TACE and plays a critical role in regulating splenic cell survival and homeostasis.
 

3.01 Serotonin Mediated Neuro-Intestinal Regulation of Immune Development

Posted on January 18, 2018

J. H. Neilson1, K. Brawner1, S. Dees1, A. Chen1, J. Bibb1, C. Martin1  1University Of Alabama At Birmingham,Department Of Surgery,Birmingham, AL, USA

Introduction: Intestinal epithelial barrier function is critical for appropriate immunity and disease protection. Dysregulation of neural hormone serotonin can affect intestinal subsepratibility to inflammation, However the mechanisms regulating these findings are poorly understood. Serotonin is synthesized through the conversion of tryptophan being rate limited by the enzyme tryptophan hydroxylase (TH). Tryptophan is metabolized into a variety of different molecules, some of which are ligands to the aryl-hydrocarbon Receptor (AhR). AhR is important in intestinal immune function. We hypothesized that depleting serotonin by inhibiting TH would limit inflammation and increase the protective barrier of the gut. One mechanism of protection could be through increased AhR stimulation.

Methods:  8-week-old C57/B6 mice were treated for 5 consecutive days with a 150 mg/kg dose of the TH inhibitor 4-Chloro-L-phenylalanine (PCPA). After 5 days, drug efficacy was measured by quantifying serum serotonin levels. Immune function was measured by quantifying fecal IgA by ELISA. To assess barrier function and bacterial translocation, mesenteric lymph node (MLN) samples were homogenized and plated on Schaedler agar in aerobic conditions. Colonies were counted after 3 days of incubation. AhR ligand availability was measured using a cell-based luciferase reporter assay. HCT 116 cells were used that has been stably transfected with the DRE-driven firefly luciferase construct.

Results: Serotonin was depleted in the PCPA treated mice from an average of 7800 ng/mL (n=3) to 4300 ng/mL (n=3) to a significant degree within the intestine (P=0.004). IgA in the stool showed no difference with pretreated mice averaging 36 µg/mL and an average of 37 µg/mL after treatment (n=6, P=0.89). There was a significant decrease in bacterial translocation in treated mice. Treated mice averaged 4.5 colonies per plate (n=11) while controls averaged 1057 colonies per plate (n=6, P=0.013). The AhR luciferase assay also showed a significant increase in AhR activity in the stool showing a light intensity with an average of 2815 (n=3) for control and 5454 (n=3) for treated mice (P=0.013).

Conclusion: Serotonin depletion augments intestinal barrier function resulting in less bacterial translocation by MLN culture, but has no effect on IgA secretion. This could be due to increased AhR activity causing a variety of effects of the intestinal barrier. AhR signaling is critical for intestinal immune development. One mechanism to explain this finding could be differences in immune cell development allowing for decreased bacterial translocation in serotonin depleted mice. Targeted serotonin regulation may be a way to regulate bacterial translocation in patients at risk for infectious intestinal diseases.

28.09 Patient-Reported Health Literacy Scores Associated With Readmissions Following Surgery

Posted on January 18, 2018

S. Baker1,2, L. Graham1,2, E. Dasinger1,2, T. Wahl1,2, J. Richman1,2, L. Copeland3, E. Burns4, J. Whittle4, M. Hawn5, M. Morris1,2  1University Of Alabama at Birmingham,Birmingham, AL, USA 2VA Birmingham Healthcare System,Birmingham, AL, USA 3VA Central Western Massachusetts Health Care System,Leeds, MA, USA 4Milwaukee VA Medical Center,Milwaukee, WI, USA 5VA Palo Alto Healthcare Systems,Palo Alto, CA, USA

Introduction: Hospital readmissions following surgery can be expensive and taxing on patients. Identifying mutable factors in predicting readmissions would be advantageous to both patients and healthcare systems. We hypothesized that patients with lower health literacy (HL) were more likely to be readmitted to the hospital following surgery.

Methods: We enrolled 734 patients undergoing general, vascular, or thoracic surgery at 4 Veterans Affairs (VA) Medical Centers, August 2015-June 2017. Patients were eligible if their post-operative hospital stay was more than 48 hours and they were discharged alive. Trained interviewers assessed patients’ overall health on the day of discharge using the Veterans Health Survey (VR12) Physical and Mental Component Scores (PCS; MCS). Health literacy was assessed by the 3-question Chew Health Literacy Questionnaire (HLQ), and the quality of the discharge transition by the Care Transition Measure (CTM-15). Patients were followed for 30 days post-discharge for readmission or emergency department (ED) use. A follow-up telephone interview at day 30 identified readmissions to non-VA hospitals. The HLQ summed three 5-point items (range 0-12); scores of 0-3 indicated adequate health literacy while scores of 4-12 indicated marginal or possibily inadequate health literacy. Bivariate and multivariable analyses examined correlations between HL and each outcome, 30-day readmission or ED use. Logistic regression models adjusted for clinical and demographic covariates.

Results: At the time of discharge, 33% of patient responses were consistent with inadequate HL (HL-low, n=245). Patients with adequate HL (HL-high) had better overall physical and mental health compared to patients with HL-low (PCS 32.0 vs. 29.5, p=0.01; MCS 49.7 vs 45.7, p<0.01) and reported higher-quality discharges (CTM-15 Mean: 3.3 vs 3.2, p<0.01). The overall 30-day readmission rate was 16% (n=124), however, it was 14% for patients with HL-high compared to 21% with HL-low (p<0.01). After adjusting for overall health (VR12), patients with HL-low were 1.5 times more likely to experience a readmission versus HL-high (OR=1.5, 95% CI=1.0-2.2); patterns of ED use were similar (OR for HL-low =1.38; 95% CI=0.95-2.01). Among the HL factors, patients who reported: (1) always having difficulty understanding written information were 2.8 times more likely to be readmitted (95% CI= 1.0-2.3), (2) not always confident filling out medical forms were 1.6 times more likely to be readmitted (95% CI= 1.1-2.4), and (3) ever requiring help to read hospital materials were 1.5 times more likely to be readmitted (95% CI= 1.2-6.5).

Conclusion: Low health literacy is common among VA surgery patients and an important contributor to readmission. Future work should focus on early identification of inadequate HL and the development of interventions to educate and empower this vulnerable population prior to discharge. 

28.04 Improvements in Surgical Mortality: The Roles of Complications and Failure to Rescue

Posted on January 18, 2018

B. T. Fry1,2, J. R. Thumma2, J. B. Dimick2,3  3University Of Michigan,Department Of Surgery,Ann Arbor, MI, USA 1University Of Michigan,Medical School,Ann Arbor, MI, USA 2University Of Michigan,Center For Healthcare Outcomes And Policy,Ann Arbor, MI, USA

Introduction: Surgical mortality has declined considerably over the last decade. While most hospitals have reduced mortality to some degree, much can be learned from how hospitals with the largest reductions achieved their improvement. Specifically, the roles of reducing complications and improving rescue from complications once they occur (known as failure to rescue or FTR) remain unclear. This study sought to understand which of these factors plays a larger role in reducing surgical mortality.

Methods: Using Medicare Provider Analysis and Review files, we performed a retrospective, longitudinal cohort study of patients who underwent abdominal aortic aneurysm (AAA) repair, pulmonary resection, colectomy, and pancreatectomy. We then calculated hospital-level risk- and reliability-adjusted rates of 30-day mortality, serious complications, and FTR for these patients in two time periods: 2005-2006 and 2013-2014 (n=699,771 patients). Serious complications were defined as the presence of one or more of eight complications plus a procedure-specific length of stay of greater than the 75th percentile. FTR was defined as death occurring in a patient with at least one serious complication. Hospitals were stratified into quintiles by change in mortality over time with average rates of 30-day mortality, serious complications, and FTR reported for each quintile. Variance partitioning was used to determine the relative contributions of differences in complication and FTR rates to the observed changes in hospital-level surgical mortality between time periods.

Results: After stratifying by reductions in mortality from 2005-2014, the top 20% of hospitals had decreased mortality rates by 3.4% (8.9 to 5.5%, p<0.001), decreased complication rates by 1.8% (15.2 to 13.4%, p<0.001), and decreased FTR rates by 7.4% (25.8 to 18.4%, p<0.001). In contrast, the bottom 20% of hospitals had actually increased mortality rates by 1.1% (6.9 to 8.0%, p<0.001), increased complication rates by 0.9% (14.6 to 15.5%, p<0.001), and increased FTR by 0.6% (22.1 to 22.7%, p<0.001). When examining the factors most associated with reductions in mortality, we found that decreased FTR explained 69% of the improvement in hospitals’ mortality rates over time, whereas decreased complication rates accounted for only 6% of this improvement. 

Conclusion: Hospitals with the largest reductions in surgical mortality achieved these improvements largely through reducing FTR rates and not by reducing serious complication rates. This suggests that hospitals aiming to reduce surgical mortality should engage in efforts focused on improving rescue from serious complications.  

28.05 Inconsistent Benchmarking by Mortality vs Readmission: Implications for Medicare Payment Metrics

Posted on January 18, 2018

C. K. Zogg1,2,3, Z. G. Hashmi3, J. R. Thumma2, A. M. Ryan2, J. B. Dimick2  1Yale University School Of Medicine,New Haven, CT, USA 2University Of Michigan,Center For Healthcare Outcomes And Policy,Ann Arbor, MI, USA 3Brigham And Women’s Hospital,Center For Surgery And Public Health,Boston, MA, USA

Introduction: Since passage of the 2010 ACA, the Centers for Medicare & Medicaid Services have begun to tie surgical reimbursements to hospital performance on 30-day mortality and readmission rates. Under this system, there remain concerns that some high-performing hospitals with a lower risk of 30-day mortality may suffer from higher readmissions simply by saving lives. This creates the potential for reimbursement strategies to unfairly penalize such hospitals for providing superior care. The objective of this study was to determine whether benchmarking results are similar when hospitals are profiled based on 30-day mortality versus readmission rates.

Methods:  Older adult (≥65y) patients presenting for 3 common operations (elective colectomy, CABG, AAA) were identified using 2013-2014 100% Medicare fee-for-service claims. Each hospital was benchmarked on each outcome using risk-adjusted observed-to-expected (O/E, current Medicare standard) and shrinkage-adjusted (SA) rates (multilevel-modeling that accounts for variability due to hospitals with small sample-size). These estimates were then used to generate hospital performance profiles which were compared using: 1) linear regression with weighted correlation coefficients, 2) concordance among high/average/low performers with thresholds set as ±1 SD above/below the mean, and 3) magnitude of difference in quintile rank.

Results: Little to no correlation was found between mortality and readmission (Figure)—colectomy r=0.110; κ=0.002, p-value=0.111. Only 26.4% (707/2673) of hospitals performing colectomies had identical rankings for both metrics (CABG 24.8%, AAA 26.2%). Four percent had completely different rates (CABG 12.9%, AAA 12.5%)—an inverse association which became significant, r=-0.241, and markedly more pronounced, 25.0%, among high-risk patients with LOS ≥30d. SA demonstrated similar results. Discrepancies between mortality/readmission ranks were most pronounced among large hospitals (4-quintile difference vs no difference, ≥400 beds: 21.5 vs 17.9%, p=0.014), with more surgical admissions (highest quartile: 32.3 vs 29.3%, p<0.001), lacking certifications from organizations such as the Joint Commission and Council of Teaching Hospitals but with a larger resident role, more complex case-mix, and lower number of RNs/bed (p≤0.013 for each).

Conclusion: Mortality and readmission benchmarking do not identify high-quality hospitals in the same way. This creates a dichotomy between standards used to determine Medicare reimbursement rates. Implementation of benchmarking that reflects multiple aspects of quality is needed in order to avoid inconsistent penalization of large, outlying, teaching hospitals providing high-quality mortality care.

22.02 The Gut-Liver Axis: The Source of Inflammation in Aging

Posted on January 18, 2018

F. Adiliaghdam1, F. Kuehn1, S. R. Hamarneh1, R. Vasan1, J. M. Ramirez1, E. Samarbafzadeh1, E. Liu1, Y. Liu1, R. A. Hodin1  1Massachusetts General Hospital,General Surgery,Boston, MA, USA

Introduction: Inflammaging, a chronic low-grade inflammatory state linked to persistent endotoxemia, is thought to play a crucial role in human aging and age-related diseases. The portal system resides at the interface between the liver and gut and is likely the main entry port for the intestinal inflammatory mediators into the systemic circulation. Based on our previous discovery that mice lacking the brush border enzyme intestinal alkaline phosphatase (IAP) have an accelerated aging phenotype, we used this as a leaky gut model to understand the contribution of the portal system in the inflammaging process.  

 

Methods: C57/BL6 WT or IAP KO mice of different ages (3-22 months) were used for the aging model. Liver inflammation was assessed as an indirect proinflammatory characteristic of portal vein. To study the direct effects of portal vein serum, primary mouse macrophages were incubated with portal or systemic serum from different aged mice and inflammatory gene expression measured. LPS levels were measured in both systemic and portal serum using the LAL assay.

 

Results: We found an age-dependent increase in the inflammatory cytokine levels in the livers of WT mice (p<0.05 for TNF- α and p<0.001 for IL-6). IAP-deficient mice showed significantly higher cytokine levels in their liver compared to their WT littermates (mRNA fold change for TNF-α:2.23, p<0.05 and 3.89 for IL-6, p<0.01) The amount of LPS in portal and systemic serum increased as a function of age, but were > 1000 times higher in portal compared to systemic serum, regardless of age or genotype (p<0.001).  The absence of IAP was associated with significantly more LPS in both portal and systemic blood circulations. In young mice, serum LPS was higher in KO vs WT mice, 2.32 fold systemically and 1.32 fold portally. A similar trend was seen in old mice, where systemically ratios increase by 3.33 and portally 1.86 fold. Upon incubation of target cells, we found that both systemic and portal serum from old animals induced a significantly higher inflammatory response than serum derived from young animals (2.89 and 2.73 fold increase, respectively, p<0.01 and <0.05). There was also a highly significant difference between the magnitude of TNF-α expression induced by portal compared to systemic serum (4.06 and 6.02 fold increase in young and old group, respectively. p<0.01). Finally, portal serum from IAP KO mice resulted in a more pronounced inflammatory response than serum from their WT counterparts (1.89 and 3.44 fold increase in young and old group, respectively. p<0.001).

 

Conclusion: Portal vein serum contains proinflammatory characteristics that increase with aging. Targeting the “leaky gut” with IAP treatment could prevent the entry of gut-derived inflammatory mediators into the portal system, thus representing a novel therapy to prevent a variety of gut-derived systemic diseases.

22.03 Caspase-11 Mediated HMGB1 Release from the Liver Drives Immune Cell Pyroptosis in Sepsis

Posted on January 18, 2018

W. Li1,2, M. Deng1, B. Lu3, Y. Tang3, M. Scott1, Q. Wang1, T. R. Billiar1  1University Of Pittsburgh,Surgery,Pittsburgh, PA, USA 2The 3rd Xiangya Hospital Of Central South University,Surgery,Changsha, HUNAN, China 3The 3rd Xiangya Hospital Of Central South University,Department Of Hematology And Research Institute Of Immunology,Changsha, HUNAN, China

Introduction: Caspase-11, a recently described intracellular receptor for endotoxin (LPS) initiates the noncanonical inflammasome and induces pyroptotic cell death in immune cells during endotoxemia. It is unknown how LPS is delivered to cytosolic caspase-11 in endotoxemia or sepsis. We hypothesis that HMGB1, a known LPS-binding protein that contributes to lethality in sepsis, would deliver LPS to the cytosol of macrophages.

Methods: Experiments were carried out in cultured murine macrophages exposed to LPS in vitro and in a CLP sepsis model in vivo. We generated global caspase-11-/- , TLR4-/- and RAGE-/- mice as well as mice with selective deletion of caspase-11, HMGB1 or TLR4 from myeloid cells or hepatocytes. All in vivo experiments included 6-20 mice per group.

Results: In vitro experiments established that HMGB1 efficiently delivered LPS to the cytosol of cultured macrophages through RAGE-dependent uptake of HMGB1-LPS complexes. This in turn, led to LPS delivery to caspase-11 in the cytosol and pyroptosis.

In vivo, hepatocyte specific deletion of TLR4, caspase-11 or HMGB1 suppressed circulating HMGB1 levels, improved survival and bacterial clearance, and prevented immune cell death in the spleen during sepsis. In contrast, myeloid cell specific deletion of TLR4 or HMGB1 had no effect on circulating HMGB1 levels or immune cell death in sepsis, while caspase-11 deletion prevented immune cell death.

 

Conclusion: These findings indicate that hepatocytes are the dominant source of HMGB1 in sepsis. Surprisingly, the release of HMGB1 from the liver requires both TLR4 and caspase-11 in hepatocytes. The systemic release of HMGB1 drives caspase-11 dependent pyroptosis in immune cells. These studies identify a novel circuit that involves the LPS-sensing pathway in the liver for the regulation of systemic release of HMGB1 in sepsis. This liver-derived HMGB1 is required for caspase-11 dependent immune cell pyroptosis and lethality. 

 

21.01 Are Residents Really Burned Out? A Comprehensive Study of Surgical Resident Burnout and Well-Being

Posted on January 18, 2018

B. Hewitt1, J. W. Chung1, A. R. Dahlke1, A. D. Yang1, K. E. Engelhardt1, E. Blay1, J. T. Moskowitz2, E. O. Cheung2, F. R. Lewis3, K. Y. Bilimoria1  1Northwestern University,Surgical Outcomes And Quality Improvement Center,Chicago, IL, USA 2Northwestern University,Osher Center For Integrative Medicine,Chicago, ILLINOIS, USA 3American Board Of Surgery,Philadelphia, PENNSYLVANIA, USA

Introduction:  Despite great interest in resident wellness, little is known about actual rates of resident burnout as current data are limited by poor response rates, small sample sizes, or use of non-validated measures. Surgical residents are hypothesized to be at particular risk for burnout and poor well-being. We used novel national survey data with responses from nearly all U.S. general surgery residents to (1) examine burnout and poor well-being prevalence and (2) identify factors associated with burnout and well-being.

Methods:  All general surgery residents were surveyed (99% response rate) at the time of the January 2017 American Board of Surgery In-Training Examination (ABSITE) regarding wellness, duty hour violations, preparation for residency, and occupational safety. The main resident wellness outcomes were burnout (abbreviated Maslach Burnout Inventory – 6 items) and psychiatric well-being (General Health Questionnaire-12 which identifies those at risk for non-psychotic psychiatric illness). Hierarchical logistic regression analyses were performed to examine resident and program factors associated with burnout and well-being.

Results: Of 7,441 residents offered the survey, 7,387 residents (99.3%) in 260 surgical residency programs completed all items related to resident wellness. Overall, burnout was reported in 23.8% (n=1,756) of residents and poor psychiatric well-being in 44.3% (n=3,270). From the burnout assessment, 16.0% (n=1,184) of residents responded that they “do not really care what happens to some patients” at least a few times a month, and 18.1% (n=1,337) of residents responded that they daily “feel fatigued in the morning having to face another day on the job.” In multivariable models, burnout was more likely among male residents (OR 1.15 [95% CI 1.01-1.31]), those who felt unprepared for residency (OR 1.65 [95% CI 1.44-1.90]), and those who violated the 80 hour weekly average duty hour limit (violations in 1-4 of the past 6 months: OR 1.54 [95% CI 1.35-1.77]; violations in ≥5 months: OR 2.35 [95% CI 1.80-3.07]) compared to no violations. Burnout was not significantly associated with post graduate year (PGY). Poor psychiatric well-being was associated with similar factors with the exception of female residents (OR 1.25 [95% CI 1.12-1.38]) and PGY 1 residents (OR 1.19 [95% CI 1.04-1.35]) compared to PGY 4/5 residents who were more likely to report poor psychiatric well-being. There was no significant difference in burnout or psychiatric well-being between the Flexible and Standard arms of the FIRST Trial.

Conclusion: In this national survey including 99% of clinically active surgical residents in the U.S., burnout and poor psychiatric well-being were prevalent in surgical residents and more likely in residents who reported feeling unprepared for residency and those who violated duty hour limits. Solutions to improve resident wellness are needed and should address these associated factors.

 

21.02 Racial and Ethnic Disparities in Promotion and Retention of Academic Surgeons

Posted on January 18, 2018

G. Eckenrode1,2, M. Symer1, J. Abelson1, A. Watkins1, H. Yeo1,2  1Weill Cornell Medical College,Surgery,New York, NY, USA 2Weill Cornell Medical College,Healthcare Policy,New York, NY, USA

Introduction: Racial and ethnic diversity is low in academic surgery, especially in leadership positions. However, no study has quantified differences in the rates of retention and promotion of racial and ethnic minority surgeons in academia. We used the American Association of Medical Colleges (AAMC) Faculty Roster to track a large cohort of academic surgeons and evaluate their rates of promotion and retention by race.

Methods: The AAMC Faculty Roster is a comprehensive database which aggregates national, longitudinal data on academic faculty. All first-time assistant and associate professors appointed between January 1, 2003 and December 31, 2006 in surgery were included. Individuals were followed for up to 10 years from their initial appointment; until they were promoted, stayed at their current rank, or left full-time academia. Faculty who switched institutions were included in the analysis. Log-rank test was used to determine the impact of race and ethnicity on promotion (increase in academic rank) and retention (persistence in academic surgery regardless of rank). Individuals of Black, Hispanic, or Other race/ethnicity (such as American Indian or other/multiple/unknown) were grouped due to data limitations. 

Results:There were 3,966 academic surgeons who began academic appointments from 2003 to 2006, of whom 2,683 were assistant professors and 1,283 were associate professors. Faculty were predominantly White (n=2,617), followed by Asian (n=559), and Black, Hispanic, or Other race/ethnicity (n=790). There was a non-significant trend toward lower promotion of Black/Hispanic/Other assistant professors (Black/Hispanic/Other 26.7% promoted at 10 years, Asian 33.3%, White 34.4%, p=0.07). There was a similar difference in 10-year promotion rates of associate professors between these groups (Black/Hispanic/Other n=53, 28.8%; Asian n=43, 30.3%; White n=294, 30.7%; p=0.10). However, retention rates were significantly higher for White assistant professors (n=1,017, 61.3% retained at 10 years) than Asian (n=220, 52.8% retained) or Black/Hispanic/Other faculty (n=308, 50.8% retained; p<0.01). There was no significant difference in 10-year retention rates among associate professors based on race/ethnicity (Black/Hispanic/Other 71.2%, Asian 69.7%, White 69.3%, p=0.72).

Conclusion:Overall, promotion rates in academic surgery over a 10-year period were low, with a trend to lower rates among underrepresented minorities. In addition, there is a clear disparity in the retention of minority assistant professors of surgery. Other differences in the retention and promotion of minority faculty were not significant, possibly due to the small numbers of minority faculty even in this national study. Racial/ethnic minority faculty face unique barriers in remaining in academic surgery particularly at the start of their career. To build a diverse workforce in academic surgery, a renewed focus should be made on retaining early-career minority faculty.

21.03 Editorial (Spring) Board?: Gender Composition in High-Impact General Surgery Journals

Posted on January 18, 2018

C. A. Harris1, T. Banerjee7, M. Cramer4, S. Manz6, S. Ward5, J. B. Dimick3, D. A. Telem2  1University Of Michigan,Division Of Plastic Surgery, Department Of Surgery,Ann Arbor, MI, USA 2University Of Michigan,Michigan Women’s Surgical Collaborative,Ann Arbor, MI, USA 3University Of Michigan,Department Of Surgery,Ann Arbor, MI, USA 4Cornell University,Ithaca, NY, USA 5University Of Michigan,Division Of Cardiac Surgery, Department Of Surgery,Ann Arbor, MI, USA 6University Of Michigan,Ann Arbor, MI, USA 7University Of Michigan,Institute For Health Policy And Innovation,Ann Arbor, MI, USA 8University Of Michigan,Institute For Health Policy And Innovation,Ann Arbor, MI, USA

Introduction: Serving on an editorial board is an important step in many surgeons’ careers; however, evidence suggests that access to these positions may differ based on gender. Analyses of medical journals indicate although women’s representation is improving, they remain a clear minority. Whether similar trends exist in surgery and whether women surgeons face different qualification thresholds for appointment remains unknown. To address this knowledge gap, we quantify the current gender composition of ten high-impact surgery journals, evaluate qualification metrics by gender, and delineate how board composition has changed over time.

Methods: Ten prominent general surgery journals were selected for inclusion based on impact factor. Editor characteristics were assigned using faculty websites, Scopus profiles, and the American Board of Surgery certification database. We performed cross-sectional analyses of editorial board composition by gender for 1997, 2007, and 2017 using univariate and logistic regression analysis. Variation in qualifications by gender was assessed by comparing H-index, academic rank, and number of additional degrees. Gender-based differences in editorial board member turnover and multiple board positions were evaluated for each time interval.

Results: Over 20 years, women’s editorial presence has increased from 5% to 19%. Initial univariate analysis demonstrated significant qualification differences. Compared to women, men had higher mean H-indices (39.1 vs 21.9; p<0.001) and more full professorships (70.2% vs 55.8% p=0.02); whereas, a higher percentage of women had additional degrees (36.1% vs 21.9% p=0.004). Following logistic regression controlling for length of time since board certification, these associations became non-significant (degrees p= 0.051; academic rank p=0.56; H-index p=0.35). Both women and men were equally likely to hold multiple board positions (1997 p=0.74; 2007 p=0.42; 2017 p=0.69). Journals retained higher proportions of men in each time interval (1997-2007 p=0.003; 2007-2017 p= <0.001; 1997-2017 p=0.01) and retention rates increased over time (Figure 1).

Conclusion: Women surgeons have a small but growing presence on surgical editorial boards, and any qualification differences by gender are likely attributable to practice length. Although this suggests improved gender parity, gaps remain, and may be perpetuated by inequitable retention. More importantly, rising retention rates may limit next-generation surgeons' opportunities regardless of gender. Strategies such as imposing term limits or instituting merit-based performance reviews may help balance the need for high-level expertise with efforts to ensure that editorial boards capture the field’s changing demographics.

 

21.04 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.

 

20.10 Medicare's HAC Reduction Program Disproportionately Affects Minority-Serving Hospitals

Posted on January 18, 2018

C. K. Zogg1,2, J. R. Thumma2, A. M. Ryan2, J. B. Dimick2  1Yale University School Of Medicine,New Haven, CT, USA 2University Of Michigan,Center For Healthcare Outcomes And Policy,Ann Arbor, MI, USA

Introduction: In FY2015, Medicare began reducing payments to hospitals with high adverse-event rates. Termed the Hospital Acquired Condition (HAC) Reduction Program, concern has been expressed that HAC penalties could adversely affect minority-serving hospitals, leading to reductions in resources and exasperation of disparities among hospitals with the greatest need. The objective of this study was to examine the extent to which a hospital’s percentage of minority patients associates with FY2017 a) overall/domain-specific HAC scores and b) HAC penalty receipt. Differences in socioeconomic status (SES) and hospital receipt of DSH payments (a marker of safety-net status) were also assessed.

Methods:  Older adult (≥65y) inpatients presenting for eight common surgical conditions were identified using 2013-2014 100% Medicare fee-for-service claims. Records were matched to risk-adjusted FY2017 HAC scores/penalties and hospital-level data from Medicare Hospital Impact files and the AHA Annual Survey Database. Differences were compared using multilevel logistic regression and calculation of absolute percentage-point change. Restricted analyses addressed the possibility that marginal changes among the most vulnerable (likely to be penalized) institutions could be driving the differences observed.

Results: As a hospital’s percentage of minority patients increased, climbing from 1.0 to 25.1%, average HAC scores also increased, rising from 5.8 to 6.3 (higher values indicate worse scores). Increases in penalties did not follow the same stepwise increase, instead exhibiting a marked jump within the highest decile of minority-serving extent (45.7 vs 36.7%; OR[95%CI]: 1.45[1.42-1.47])—absolute difference +8.9% (Figure). Similar patterns were seen for safety-net (1.44[1.42-1.47]) and low SES-serving (1.38[1.35-1.40]) hospitals. Restricted analyses accounting for the influence of teaching status and severity of patient case-mix both accentuated differences in penalties when limiting hospitals to those at highest risk (more residents-to-beds, more severe)—absolute differences +13.9% and +20.5%. Restriction to high operative volume, in contrast, reduced the penalty difference—absolute difference +6.6%.

Conclusion: Minority-serving hospitals are being disproportionately affected by the HAC Reduction Program. While scores followed a stepwise increase, disparities in penalty allocation were isolated to hospitals with the largest minority-serving extent—a finding which became more pronounced among hospitals with an already heightened risk of penalty receipt. As the program continues to develop, efforts are needed to identify and protect patients in vulnerable institutions in order to ensure that disparities do not increase.

 

20.06 Gender Disparities in Retention and Promotion of Academic Surgeons: A Prospective National Cohort

Posted on January 18, 2018

N. Z. Wong1, J. S. Abelson1, M. Symer1, H. L. Yeo1,2  1Weill Cornell Medicine,Surgery,New York, NY, USA 2Weill Cornell Medicine,Healthcare Policy And Research,New York, NY, USA

Introduction: Women comprise 38.3% of general surgery residents in the U.S., but only 9.8% of full professors in academic general surgery. Previous studies have identified factors contributing to the underrepresentation of women in academic surgery, but no study has quantified the rates of retention and promotion of early and mid-career female academic surgeons.  As a result, we used data from the American Association of Medical Colleges (AAMC) Faculty Roster to track a national cohort of academic surgeons over time to evaluate gender disparities in retention and promotion.

Methods: Data were extracted from the AAMC Faculty Roster for all first-time appointments of full-time assistant and associate professors of surgery starting their academic careers between January 1, 2003 and December 31, 2006; these faculty were individually followed over 10 years to determine if they stayed in full time academic practice (retained) or were promoted.  Cumulative counts of retained or promoted faculty at the end of the 10-year follow up period were compared using Fisher’s exact test. The impact of gender on retention and promotion during the study period was analyzed with survival analysis by log-rank test.

Results: The analysis included retention and promotion data for 3,966 early and mid-career (assistant and associate professors) academic surgeons. Over the 10-year follow up, there were no differences in retention rates between women and men for assistant professors (50% vs. 46%, p=0.10) or associate professors (39% vs. 35%, p=0.27). Survival analysis did not demonstrate a significant difference in retention rates by gender for either academic level (assistant/associate). However, when comparing rates of promotion, women both at the assistant (29% vs 34%, p=0.02) and associate (32% vs. 42% p=0.01) level were promoted at significantly lower rates compared to their male collogues. Furthermore, 10-year survival analysis demonstrated a significant difference in promotion rates in full-time academic surgery for both assistant and associate professors (log-rank p=0.03 and p=0.03, respectively).

Conclusion: This study is the first to quantify gender disparities in retention and promotion rates among U.S. academic surgeons using a comprehensive and prospective national database. Findings suggest that academic surgery retention rates are similarly low between women and men, while promotion rates are significantly lower for women faculty. These findings demonstrate that women surgeons are at increased likelihood of non-promotion in academia, likely contributing to decreased gender diversity at the full professor level. We should consider strategies to improve retention of junior faculty (both men and women) over time.  Additional research on the relationship between gender and promotion will be critical to effectively increasing and maintaining workforce diversity.
 

20.07 Improvements in Surgical Mortality: The Roles of Complications and Failure to Rescue

Posted on January 18, 2018

B. T. Fry1,2, J. R. Thumma2, J. B. Dimick2,3  3University Of Michigan,Department Of Surgery,Ann Arbor, MI, USA 1University Of Michigan,Medical School,Ann Arbor, MI, USA 2University Of Michigan,Center For Healthcare Outcomes And Policy,Ann Arbor, MI, USA

Introduction: Surgical mortality has declined considerably over the last decade. While most hospitals have reduced mortality to some degree, much can be learned from how hospitals with the largest reductions achieved their improvement. Specifically, the roles of reducing complications and improving rescue from complications once they occur (known as failure to rescue or FTR) remain unclear. This study sought to understand which of these factors plays a larger role in reducing surgical mortality.

Methods: Using Medicare Provider Analysis and Review files, we performed a retrospective, longitudinal cohort study of patients who underwent abdominal aortic aneurysm (AAA) repair, pulmonary resection, colectomy, and pancreatectomy. We then calculated hospital-level risk- and reliability-adjusted rates of 30-day mortality, serious complications, and FTR for these patients in two time periods: 2005-2006 and 2013-2014 (n=699,771 patients). Serious complications were defined as the presence of one or more of eight complications plus a procedure-specific length of stay of greater than the 75th percentile. FTR was defined as death occurring in a patient with at least one serious complication. Hospitals were stratified into quintiles by change in mortality over time with average rates of 30-day mortality, serious complications, and FTR reported for each quintile. Variance partitioning was used to determine the relative contributions of differences in complication and FTR rates to the observed changes in hospital-level surgical mortality between time periods.

Results: After stratifying by reductions in mortality from 2005-2014, the top 20% of hospitals had decreased mortality rates by 3.4% (8.9 to 5.5%, p<0.001), decreased complication rates by 1.8% (15.2 to 13.4%, p<0.001), and decreased FTR rates by 7.4% (25.8 to 18.4%, p<0.001). In contrast, the bottom 20% of hospitals had actually increased mortality rates by 1.1% (6.9 to 8.0%, p<0.001), increased complication rates by 0.9% (14.6 to 15.5%, p<0.001), and increased FTR by 0.6% (22.1 to 22.7%, p<0.001). When examining the factors most associated with reductions in mortality, we found that decreased FTR explained 69% of the improvement in hospitals’ mortality rates over time, whereas decreased complication rates accounted for only 6% of this improvement. 

Conclusion: Hospitals with the largest reductions in surgical mortality achieved these improvements largely through reducing FTR rates and not by reducing serious complication rates. This suggests that hospitals aiming to reduce surgical mortality should engage in efforts focused on improving rescue from serious complications.  

18.17 Evaluating System-Based Financial Knowledge of General Surgery Residents

Posted on January 18, 2018

L. Ferro1, E. Grenn2, C. Muncie2, D. Parrish1,2, L. Boomer1  1VCU Medical Center,Surgery,Richmond, VA, USA 2University Of Mississippi Medical Center,Surgery,Jackson, MS, USA

Introduction: The General Surgery Milestone Project was instituted by the Accreditation Council for Graduate Medical Education (ACGME) in 2015 as a new way to evaluate general surgery residents in their development into independent physicians based on six core competencies. One of these competency areas focuses on “System-Based Practice.” We hypothesized that resident cost knowledge and cost comparisons of various hospital services is poor, and this lack of knowledge affects their competency in regards to some portions of system-based practice.

Methods: The billing departments of two major academic institutions were queried regarding the charges for specific hospital services (cardiology consult, computed tomography (CT) scan of abdomen/pelvis, chest radiograph (CXR), stat complete blood count (CBC), magnetic resonance imaging (MRI) of the cervical spine, magnetic resonance cholangiopancreatography (MRCP), Hepatobiliary Iminodiacetic acid (HIDA), and right upper quadrant ultrasound). In an attempt to keep things standard, the costs were evaluated for uninsured patients. Once these costs were obtained, the general surgery residents were asked in an open ended survey the costs of each of these services. The residents’ responses were grouped and analyzed as a whole.

Results: Fifty-eight general surgery residents (83%) responded to the survey. The data was first evaluated to identify how many respondents could identify the cost of the service within 25% of the actual cost. The percent of residents that were able to name the cost of the service was low throughout (1.7% to 27.5% depending on service), with <10% of respondents being within 25% of the actual cost for cardiology consult, CXR, and CT scan of the abdomen and pelvis.  When the data was evaluated to see if respondents could come within 50% of the actual cost, the results were improved (6.9% to 53.4%).

Conclusion: The results show a significant lack of knowledge of the costs of hospital services among general surgery residents. We believe that increased education in this area would benefit residents as they progress through their training and into their practices. This improvement in resident knowledge may also lead to cost-savings for both patients and hospitals.

 

18.18 Do Residents Know Duty Hour Limits? How Communicating and Interpreting Duty Hours Impacts Compliance

Posted on January 18, 2018

R. R. Love3, A. Dahlke3, L. Kreutzer3, D. B. Hewitt2,3, K. Y. Bilimoria3, J. K. Johnson3  2Thomas Jefferson University,Surgery,Philadelphia, PA, USA 3Northwestern University,Surgical Outcomes And Quality Improvement Center (SOQIC),Chicago, IL, USA

Introduction: The Accreditation Council for Graduate Medical Education (ACGME) recently revised requirements to allow programs and residents the flexibility to establish and adhere to duty hours in a manner that optimizes patient safety, resident well-being, and education.  This study used qualitative research methods to explore Program Directors (PDs), Program Coordinators, and faculty members’ understanding of duty hour regulations and how they communicate those regulations to their residents.

Methods: Semi structured interviews were conducted with a total of 98 general surgery PDs, residents, and attending surgeons from institutions enrolled in the Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) Trial. Interviewees were asked about their understanding of duty hour regulations and how that information was communicated at their institution. Interviews were recorded, transcribed verbatim, and analyzed thematically using a constant comparative approach. This study was a sub-analysis of a larger study that examined implications of duty hour policies on resident wellbeing.

Results: Several themes related to knowledge of duty hour regulations were identified in our study such as interpreting, communicating, reporting, and compliance. Respondents reported differing levels of knowledge and understanding of duty hour regulations. Communication about duty hours occurs both formally (i.e., official correspondence given to residents and faculty from PDs or Program Coordinators regarding duty hour regulations) and informally (i.e., unofficial discussions of duty hours and implicit expectations among residents or faculty). These communications were thought to have a direct impact on how residents interpret their duty hours and how they report them. Residents who were unable to correctly identify duty hour policies may be more likely to violate those policies, which has an impact on reporting and ultimately compliance to duty hour policies.

Conclusion: Inconsistent communication of duty hours from faculty, PDs, and other residents contributes to a general lack of knowledge regarding ACGME duty hours. If residents are unaware of specific duty hour regulations, then violations seem more likely. Programs should use both formal and informal communication methods to systematically reinforce the message about duty hour regulations.

18.19 Current Trends in Training in the Surgical Management of Acute Appendicitis at a Veteran Affairs Hospital.

Posted on January 18, 2018

M. Ruiz1, S. Huerta1,2  1University Of Texas Southwestern Medical Center,Surgery,Dallas, TX, USA 2VA North Texas Health Care System,Dallas, TX, USA

Introduction:  An open appendectomy used to be one of the most common cases performed by interns and physical exam dictated operative intervention.   We hypothesize that the management of acute appendicitis has drastically changed from these previous practices.    

Methods:  This a retrospective, single institution analysis at the VA North Texas Health Care system (VANTHCS) between 7/05 to 6/17 for all patients who underwent an appendectomy (n=345).  Patients who had an appendectomy for cancer, or incidentally for other reasons were excluded (n=35) as were patients with interval appendectomies (n=16) as well as patients with perforated appendicitis (n=14).  Specific analysis for complications was performed by grouping residents as junior (PGY-1 to 3) and senior (PGY-4 and 5) to determine if there were differences in outcomes.  Using postoperative complications as a dependent variable, univariate analysis was performed using Fisher’s Exact Test for categorical and Student’s T-Test for continuous variables.  Significant variables were included in a multiple logistic regression model with postoperative complications as the dependent variable. Data are expressed as means ± SD and significance was established at a p≤0.05 (two-sided).

Results: There were 280 acute appendectomies during the study period (male=90%; age=46.0±15.7 y.o.; BMI=31.2±18.3 Kg/m2).  Of these, only 8 were performed by interns, PGY-2=30, PGY-3=154, PGY-4=25, and PGY-5=63.  There were 20 minor complications (7.1%) and 30-day mortality was zero. LOS was 3.7±4.3 days. On presentation, 91% of patients had a CT scan and 92% underwent a laparoscopic appendectomy.  Conversion rate was 5%.   Comparing patients operated by senior (PGY-4 and 5) to junior (PGY-1 to -3) residents: patients were of similar age, gender, BMI, ASA, and had similar co-morbid conditions, as well as similar WBC and blood pressure on initial presentation (all p’s > 0.05).  However, OR time was longer (67.2±36.3 vs. 59.7±24.5 min) and EBL was higher (31.4±54.1 vs. 18.5±29.8 mL); both p’s <0.05. Patients also were more likely to have a gangrenous appendix if operated on by senior residents and had a higher heart rate on initial presentation (90.6±19.2 vs. 84.6±16.4; p=0.008). Complications were 10% and 6% for senior and junior residents; respectively (OR 1.1; 95% CI 1.0 to 1.1). 

Conclusion: At the VANTHCS, most patients presenting with suspected appendicitis undergo a CT-scan.  Most cases are performed laparoscopically. Only a small fraction of appendectomies are performed by interns. Senior residents undertake the most difficult laparoscopic cases and, therefore, have more complications.   

 

18.15 Surgical Intern Case Volume Growth in the First Year of Post-graduate Training.

Posted on January 18, 2018

I. A. Woelfel1, D. Strosberg1, S. Abdel-Misih1,2, A. Harzman1,3  1Ohio State University,Department Of Surgery,Columbus, OH, USA 2Ohio State University,Surgical Oncology,Columbus, OH, USA 3Ohio State University,Colon And Rectal Surgery,Columbus, OH, USA

Introduction: The combination of work hour restrictions and a continual increase in the documentation tasks required of all physicians makes clinical efficiency of utmost importance in gaining operative time during the first year of post-graduate training. However, the majority of patient-care responsibilities during the first year of post-graduate training focus on perioperative patient care. While other studies have documented clinical efficiency through discrete observation and recording of all daily activities, we wanted to analyze efficiency by one of its anticipated outcomes: time in the operating room. The aim of this study is to determine if hypothesized increased clinical efficiency throughout the first year of post-graduate training translates into increased time in the operating room.

 

Methods: We completed a retrospective review of all the logged surgical cases from current general surgery residents during their PGY 1 (intern) year at a single large academic training program from 2011-2017. All logged cases are recorded on the General Surgery Operative Log (GSOL) of the Accreditation Council for Graduate Medical Education website by surgical residents using current procedural terminology code (CPT). The cases were categorized according to the month and rotation in which they occurred. A correlation coefficient was calculated to determine the strength of the relationship between month and the operative volume.

 

Results: The ACGME case logs for 25 interns spanning the years 2011 to 2017 were examined, yielding a total 3,751 cases for analysis. We included central line placements, endoscopy, as well as ultrasounds, while excluding intensive care unit and non-operative trauma cases. The number of cases per resident peaked in June of intern year with a median of 18 (range: 3-52) cases; a total of seven more cases than the 11 (range: 1-38) per resident in July.  The average numbers of cases per resident according to month are plotted in Figure 1. (Correlation coefficient = 0.26) Additionally it was found that Surgical Oncology had the highest case volume (Median = 23; range 3-88) while the Surgical Intensive Care Unit rotation had the lowest case volumes (Median = 4; Range 1-22).

 

Conclusion: Our results show that operative experience increases slightly throughout intern year with the highest average case experience in the final month. We hypothesize that this correlates positively with increasing efficiency in non-operative tasks such as documentation and care coordination. Therefore, increased early training in those areas may allow even greater early operative exposure for surgical residents.

 

18.13 An Interdisciplinary Approach to Surgical Skills Training Decreases Programmatic Costs

Posted on January 18, 2018

M. Snyder1, J. D’Angelo1, J. Bleedorn2, R. Hardie2, E. Foley1, J. A. Greenberg1  1University Of Wisconsin,Department Of Surgery,Madison, WI, USA 2University Of Wisconsin,School Of Veterinary Medicine,Madison, WI, USA

Introduction:
Surgical resident duty hour limitations have necessitated operative skill training outside of the OR. Low-cost box trainers and virtual reality systems are useful for resident training; however, they do not replace surgical skill wet-labs, which produce essential learning outcomes in a more realistic and transferable exercise. Unfortunately, materials and human resource requirements make wet-labs utilizing biologic samples cost prohibitive for many residency programs. To resolve this problem, our General Surgery Residency program collaborated with the Institution’s School of Veterinary Medicine Surgery Residency program to pilot a cost-effective, interdisciplinary, surgical skills curriculum.

Methods:
The General Surgery Residency Program Manager and Program Director initiated a collaboration with the Veterinary Surgery Residency.  PGY2 general surgery residents and veterinary surgery residents participated in monthly joint surgical skills practice sessions. A novel interdisciplinary surgical skills curriculum was implemented that incorporated skills beneficial to both sets of trainees.  A cost analysis was conducted for a monthly surgical skills curriculum servicing both programs independently and compared to the actual costs of the collaborative curriculum.   Quantitative and qualitative data were collected to assess learning outcomes and obtain information on session quality.

Results:
8 general surgery residents and 5 veterinary surgery residents have participated in 9 joint skills sessions, taught by both general surgery and veterinary surgery faculty.  Three of the planned sessions did not occur due to holidays and administrative challenges at the beginning and end of the academic year.  The cost analysis estimated total savings generated by the collaborative to be $33,500.00.  An iterative review of qualitative data suggests that skill sessions reinforce knowledge and reflexivity. Participants also indicate that the collaborative skills sessions are an enjoyable and valuable learning activity.

Conclusion:
The skills curriculum collaborative has proven to be a cost-effective and high quality interdisciplinary pedagogic tool. The partnership allows for mutually-beneficial resource sharing and allowed for the initiation of a surgical skills wet-lab that had previously been unavailable to both groups.  While empirical evidence suggests that this activity supports resident skills acquisition, future research will include systematic assessment of operative skill development.
 

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