48.06 Racial and Ethnic Postoperative Outcomes from a Statewide Database: the Hispanic Paradox

Posted on January 18, 2018

E. Eguia1, A. Cobb1, E. Kirshenbaum1, P. C. Kuo1  1Loyola University Chicago Stritch School Of Medicine,General Surgery,Maywood, IL, USA

Introduction: The Hispanic/Latino population in the United States have previously been shown to have, in some cases, better health outcomes than non-Hispanic Whites despite having lower socioeconomic status and greater frequency of comorbidities. This epidemiologic finding has been coined the “Hispanic Paradox” dating back to 1986. Disparities in social determinants of health between ethnic groups also exist in surgical patients but few studies have evaluated if the Hispanic Paradox exists in this cohort. The aim of our study was to examine postoperative complications between Hispanic and non-Hispanic patients undergoing high and low risk procedures. 

Methods: We conducted a retrospective cohort study analyzing adult patients who underwent high (Esophagectomy, Pancreatectomy, Abdominal Aortic Aneurysm Repair (AAA)) and low risk procedures (Appendectomy and Cholecystectomy).  The patient cohort was derived from the California Healthcare Cost and Utilization Project (HCUP) State Inpatient Database (SID) between 2006 and 2011. Patient administrative data were linked with baseline characteristics from the American Hospital Association Database. Candidate variables for the adjusted model were determined a priori and included patient demographics with ethnic group as the exposure of interest.  Analysis was performed in a mixed effects multivariable logistic regression. 

Results: Hispanic patients had lower median income and greater proportions with Medicaid or no insurance. In adjusted analysis, Hispanics had lower odds of post-operative complications from high-risk procedures such as Esophagectomy, Pancreatectomy and AAA repair (0.74 CI 0.57-0.96, 0.47 CI 0.28-0.76, 0.35 CI 0.26-0.45).  The odds ratio for major post-operative complications from both low and high-risk procedures were no different between Hispanics and non-Hispanics. Hispanics had greater odds of in-hospital death after an Esophagectomy but no difference after Appendectomy, Pancreatectomy or AAA repair when compared to non-Hispanics. In contrast, Hispanics had lower odds of in-hospital death after Cholecystectomy (0.69 CI 0.48-0.98). 

Conclusion: Hispanics had a lower odds risk or no differences in odds risk for in-hospital death or developing postoperative complications compared to non-Hispanic patients suggestive of a Hispanic paradox in surgical outcomes. Future studies are needed to further elucidate these mechanism given that US Hispanic/Latino surgical population is a diverse race which come from a variety of cultures, backgrounds, immigrant generational status and socioeconomic characteristics. Lastly, given the limited health data on Hispanics, Surgical Disparities Research should focus on improving data collection strategies. 

 

48.07 The Surgical Management of Diverticulitis

Posted on January 18, 2018

A. Mehta1, J. K. Canner2, D. T. Efron2, J. Efron2, J. V. Sakran2  1Johns Hopkins University School Of Medicine,Baltimore, MD, USA 2Johns Hopkins University School Of Medicine,Department Of Surgery,Baltimore, MD, USA

Introduction: Diverticulitis remains a common problem for patients with diverticular disease. This study compared outcomes between elective and emergent bowel resections for diverticulitis.

Methods:  We used the 2005-2011 California State Inpatient Database to identify patients who had elective or emergent large bowel resections for diverticulitis (without hemorrhage). Primary outcomes included in-hospital mortality, complications, and extended length of stay (LOS, defined as >8 days). Secondary outcomes included 30-day inpatient readmissions and predictors of emergent repairs. Analyses adjusted for clinical factors and accounted for hospital clusters.

Results: We identified 28,813 patients undergoing large bowel resections for diverticulitis (2.0% mortality rate, 17.0% complication rate, and 22.6% extended LOS rate). Among all resections, one-third (31.8%) were performed emergently and one-quarter (23.2%) included a colostomy (6.1% of elective, 60.0% of emergent). Of the 911 patients with inpatient readmissions within 30 days of discharge, 211 (23.2%) presented to a different hospital. After multivariable logistic regression, emergent resections relative to elective resections were associated with significantly higher odds of death (aOR 2.85 [95%-CI 2.16-3.76]), complications (2.01 [1.85-2.18]), and extended LOS (1.75 [1.61-1.92]) (Figure). Emergent resections were also trending towards both greater 30-day readmissions (1.19 [0.96-1.46], P=0.08) and being readmitted to a different hospital (1.45 [0.96-2.18], P=0.07). Hispanic (1.19 [1.11-1.27]), self-pay (3.68 [3.62-4.08]), and Medicaid patients (1.19 [1.08-1.30]) were associated with emergent repairs.

Conclusion: One-third of patients undergoing surgical management for diverticulitis had emergent bowel resections, which were associated with worse postoperative outcomes and were trending towards increased 30-day readmissions. Additionally, a quarter of readmitted patients presented to a different hospital and differences in surgical care existed by race and payer.

48.08 Racial/Ethnic Disparities in Surgical Outcomes for Patients with Diverticular Disease

Posted on January 18, 2018

M. Ma1, K. Feng1, L. E. Goss1, L. N. Wood1, J. S. Richman1, M. S. Morris1, J. A. Cannon1, G. D. Kennedy1, D. I. Chu1  1University Of Alabama at Birmingham,Surgery,Birmingham, Alabama, USA

Introduction: The US incidence of diverticular disease is increasing and surgery remains a key treatment option. While racial/ethnic disparities in surgical outcomes have been observed for diseases such as cancer, it remains unclear if surgical disparities exist for diverticular patients. This study aims to characterize racial/ethnic disparities that may exist between Caucasian-, African-, and Asian-Americans who have undergone surgery for diverticular disease. We hypothesized that disparities would exist with certain racial/ethnic groups having worse outcomes.

Methods: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database for 2011-2015 was queried for patients who underwent surgery for diverticular disease. Patient and procedure-level characteristics were included. The primary outcomes were 30-day mortality, 30-day readmission, post-operative complications (POCs), and length-of-stay (LOS). Bivariate tests and adjusted logistic and negative binomial regression were used to identify associations between racial/ethnic status and these outcomes.

Results: Of 20,318 patients who underwent surgery for diverticular disease, 91.5% were Caucasian-American (CA), 7.4% African-American (AfA), and 1.1% Asian-American (AsA). Asian-Americans were more likely to be normal weight (defined as 18<BMI<25; 36.6% versus 15.6%–AfA and 23.4%–CA, p<0.001), not smoke (86.9% versus 73%–AfA and 79.3%–CA, p<0.001), have lower ASA score of 1-2 (57.5% versus 41.5%–AfA and 56.4%–CA, p<0.001), and shorter operation-time (150 min versus 190 min—AfA and 166 min—CA, p<0.001). There were no differences in 30-day mortality, but African-Americans had longer post-operative LOS and higher 30-day readmission rates. African-Americans had higher rates of ileus, respiratory complications, sepsis, and bleeding requiring transfusion. On multivariate analyses—with Caucasian-Americans as reference category—African-American race remained independently associated with more post-operative ileus (OR=1.85, p<0.001), respiratory (OR=1.50, p=0.0004), sepsis (OR=1.63, p<0.001), and bleeding complications (OR=2.17, p<0.001). With African-American race as reference group, it remained independently associated with an 8% increase in LOS as compared to Caucasian-American patients (IRR 1.08, p<0.001).

Conclusion: African-Americans undergoing surgery for diverticular disease had the highest rates of 30-day readmission, LOS, and POCs including ileus, respiratory, sepsis, and bleeding complications when compared to Caucasian- and Asian-Americans. Further studies are needed to understand these observations and to develop interventions to eliminate these disparities.

48.04 Factors Associated with the Interhospital Transfer of Emergency General Surgery Patients

Posted on January 18, 2018

A. M. Ingraham1, S. Fernandes-Taylor1, J. Schumacher1, X. Wang1, M. Saucke1, C. C. Greenberg1  1University Of Wisconsin,Department Of Surgery,Madison, WI, USA

Introduction:  Transferred emergency general surgery (EGS) patients constitute a highly vulnerable, acutely ill population. Guidelines to facilitate timely, appropriate EGS transfers are lacking. We determined patient- and hospital-level factors associated with interhospital EGS transfers. Determining these factors represents a critical first step in identifying who necessitates transfer and minimizing delays to definitive care.

Methods:  Adult EGS patients (defined by American Association for the Surgery of Trauma ICD-9 diagnosis codes) were identified within the 2008-2013 Nationwide Inpatient Sample (NIS) (n=17,175,450). Patient- and hospital-level factors were examined as predictors of transfer to another acute care hospital with a multivariate proportional cause-specific hazards model. Because patients may succumb to death or discharge to other locations rather than transfer, a competing risks analysis considering the NIS design assessed the effect of risk factors for transfer. In addition to variables in the Table, the model included patient-level characteristics (sex, age, race, insurance, patient income based upon zip code, Charlson Comorbidity Index [CCI], EGS diagnosis, procedures performed, day of admission) and two hospital-level factors (total number of discharges and region).

Results: 1.8% of patients were transferred (n=317,357). Transferred patients were on average 62 years old and most commonly had Medicare (52.9% [n=167,921]), private (26.7% [n=84,851]), or Medicaid insurance (10.7% [n=34,020]). 67.8% were white. The most common EGS diagnoses among transferred patients were related to hepatopancreatobiliary (n=90,734 [28.6%]) and upper gastrointestinal tract (n=59,958 [18.9%]) conditions. Most transferred patients (n=269,215 [84.8%]) did not have a procedure prior to transfer. Transfer was more likely if patients were in small or medium versus large facilities, government versus private facilities, and rural or urban non-teaching versus urban teaching facilities (Table). Patient-level factors associated with transfer included male sex (Hazard Ratio [HR] 1.09 [95% Confidence Intervals (CI) 1.07-1.11]), CCI (HR CCI of 2 1.01 [95% CI 1.04-1.11] and HR CCI of 3 1.17 [95% CI 1.13-1.20]), and admission on a Saturday or Sunday (HR 1.04 [95% CI 1.02-1.06]).

Conclusion: We identified patient- and hospital-level characteristics of EGS transfers to another acute care hospital. Hospital-level characteristics more strongly predicted the need for transfer than patient-related factors. Consideration of these factors by providers at non-tertiary centers as they care for EGS patients in the context of the resources and capabilities of their local institutions may reduce time to definitive care and improve patient outcomes.

 

48.05 Racial Disparities in Surgical Outcomes Following Colorectal Surgery for Inflammatory Bowel Disease

Posted on January 18, 2018

M. Ma1, K. Feng1, L. N. Wood1, L. E. Goss1, J. S. Richman1, D. I. Chu1  1University Of Alabama at Birmingham,Surgery,Birmingham, Alabama, USA

Introduction: At least 3.1 million people in the US suffer from IBD, which includes Crohn’s Disease and Ulcerative Colitis. While racial/ethnic disparities in surgical outcomes have been observed in many diseases such as cancer, it is unclear if surgical disparities exist in IBD. The objective of this study was to investigate racial/ethnic disparities in surgical outcomes in a contemporary population of Caucasian-, African-, and Asian-Americans patients. We hypothesized that disparities would exist with certain racial/ethnic groups having worse outcomes. 

Methods: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database for 2011-2015 was queried for all patients who underwent surgery for IBD. Patient and procedure-level characteristics were included. The primary outcomes were post-operative complications (POCs) and length-of-stay (LOS). Bivariate tests and adjusted logistic and negative binomial regression were used to identify associations between racial/ethnic status and these outcomes. 

Results: Of 7,091 patients who underwent colorectal surgery for IBD, racial/ethnic groups included Caucasian-Americans (CA, 90.3%), African-Americans (AfA, 8.63%) and Asian-Americans (AsA, 1.07%). Asian-Americans were more likely to be normal weight (defined as 18<BMI<25; 50.7% versus 40.1%–AfA and 42.9%–CA, p<0.001), not smoke (94.7% versus 74.2%–AfA and 80%–CA, p<0.001), and have lower ASA score of 1 or 2 (61.8% versus 52.8%–AfA and 57.4%–CA, p<0.001). African-Americans had the highest rates of complication due to ileus, sepsis, and bleeding requiring transfusion. Asian- and African-American patients comparatively also had longer post-operative LOS. On multivariate analyses—with Caucasian-Americans as reference category—African-American race remained independently associated with more post-operative ileus (OR=1.43, p=0.0005), sepsis (OR=1.71, p<0.001), and bleeding complications requiring transfusion (OR=1.65, p<0.001). With Asian-American race as reference group, it remained independently associated with a 14% increase in LOS as compared to Caucasian-American patients (IRR 1.14, p<0.001). 

Conclusion: African-Americans undergoing surgery for IBD had higher rates of POCs including ileus, sepsis, and bleeding requiring transfusion when compared to Caucasian- and Asian-Americans. This population may represent a particularly high-risk group for poor outcomes and further studies are needed to understand and develop interventions to improve these outcomes.

48.02 Racial Differences in Complications Following Emergency General Surgery: Who Your Surgeon Is Matters

Posted on January 18, 2018

R. Udyavar1, A. Salim2, E. Cornwell3, Z. Hashmi1, J. Havens1,2, A. Haider1,2  1Brigham And Women’s Hospital,Center For Surgery And Public Health,Boston, MA, USA 2Brigham And Women’s Hospital,Department Of Surgery,Boston, MA, USA 3Howard University College Of Medicine,Department Of Surgery,Washington, DC, USA

Introduction:  Understanding the mechanisms that lead to health care disparities is necessary to create robust solutions and ensure that all patients receive the best possible care. Many factors, including patients’ clinical/demographic characteristics and socioeconomic issues have been examined, but the extent to which surgeon-level factors contribute to disparities has not been established. Our objective was to quantify the influence of the individual surgeon on disparate outcomes for minority patients undergoing Emergency General Surgery (EGS). 

Methods:  We analyzed the Florida State Inpatient Database (SID) and extracted all patients who underwent 1 or more of 7 EGS procedures from 2010-2014. These procedures (laparotomy, cholecystectomy, small bowel resection, colectomy, peptic ulcer disease repair, lysis of adhesions, and appendectomy) represent 80% of all EGS cases performed in the U.S. Our outcome of interest was postoperative complications, including pulmonary embolism, infection, and anastomotic leak.  To determine the individual surgeon effect, we performed multi-level random effects modeling, adjusting for clinical and hospital factors, such as comorbidities, illness severity, and hospital volume. This allowed us to determine if there was an increased adjusted odds of developing complications for black patients attributable to the individual provider.

Results: The study sample consisted of 291,497 cases performed by 1,736 surgeons at 205 hospitals. Black patients comprised 21.5% of the sample. On unadjusted analysis, the overall complication rate was 12.7%. For white patients, this was 10.7%, but for black patients, the complication rate increased to 31.2%. Black patients had a higher adjusted risk of having a complication than white patients (OR 1.32, 95% confidence interval [CI] 1.02-1.85). Between surgeons, the complication rate ranged from 3.02% and 21.7%. The proportion of the overall surgeon-level variation explained by measured clinical and hospital-level factors was 23.8%, and the proportion attributable to the individual surgeon effect was only 2.3%. However, when comparing patients according to race, the proportion of the between-surgeon variation due to the individual surgeon increased to 11.7%. This multifold increase suggests that the individual surgeon influences the degree to which black patients are more susceptible to experiencing a complication than their white counterparts.

Conclusion: This multi-institution analysis within a single large state demonstrates that not only do black patients have a higher risk than white patients of developing a complication after undergoing EGS, surgeon-level effects account for a larger proportion of the between-surgeon variation when comparing the two demographics. This suggests that there are factors both measurable and unmeasurable at the individual surgeon level that contribute to racial disparities in EGS.  

 

48.03 Survey of Surgeons’ Perspectives of Wound Care Centers for Chronic Wound Care

Posted on January 18, 2018

V. Rendell1, T. J. Esposito2, A. Gibson1  2UnityPoint Health,Wound Care And Hyperbaric Medicine,Peoria, ILLINOIS, USA 1University Of Wisconsin,Department Of General Surgery,Madison, WI, USA

Introduction: Chronic wounds affect an estimated 6.5 million patients in the United States (US). The aging population and obesity epidemic in the US are expected to intensify the burden of disease from chronic wounds. Comprehensive wound care centers have been well described to improve patient outcomes. Despite this, little is known regarding surgeon participation in wound centers, particularly surgeons’ opinions of their potential role in wound care centers.

Methods:  The memberships of the American College of Surgeons and the American Association for the Surgery of Trauma were solicited via email to participate in an online Qualtrics survey as a convenience sample. The survey consisted of 60 multiple choice and Likert scale type questions covering demographics, characterization of wound centers at the surgeons’ practices, and surgeons’ professional experiences with wound centers. Results were reported as percentages out of total responses or means with standard deviations (SD). 

Results: A total of 364 surgeons responded to the survey. Respondents were mostly male (83%) with a mean age 57.4 years (SD 10.7yr). Respondents were in practice 24.6 years on average (SD 11.7yr). General surgeons represented 34% of respondents while 26% classified themselves as acute care surgeons, 21% plastic surgeons, 9% vascular surgeons, and 10% burn surgeons or other. The majority (73%) were in group practice with over half (58%) in a hospital based setting. Nearly all were board certified (98%), but only 6% were certified by the American Board of Wound Management. A wound center existed where 69% of the respondents practiced, and 61% utilized the centers. The majority of wound center directors were general surgeons (49%) followed by plastic surgeons (20%). Respondents’ perceptions of wound care centers are summarized in Figure 1. Respondents had a mostly favorable experience with wound centers and indicated interest in participating in a wound practice. Most respondents (53%) were interested in formal wound care/hyperbaric oxygen therapy certification. Respondents were overall unsure of the financial aspects of running a wound center and indicated concern for increased cost to patients. Respondents generally perceived a benefit of wound centers for patient care and wound healing time. 

Conclusion: With increasing burden of disease from chronic wounds in the US, there exists an unmet need for comprehensive wound care management. Surgeons are interested in transitioning their focus to wound care as part of their career and pursuing advanced wound care training. Further efforts are needed to educate surgeons with interest in wound care specialization and create a pathway for surgeons to become directors of wound centers.

48.01 Changes in General Surgery: Market Share, Billing Practices, and Social Disparities in Price

Posted on January 18, 2018

J. Tseng1, B. Loper1, A. V. Lewis1, E. Ngula1, R. F. Alban1  1Cedars-Sinai Medical Center,Department Of Surgery,Los Angeles, CA, USA

Introduction:
Healthcare is one of the largest sectors in the economy, and its expenditures are rapidly growing.  Nationwide efforts are being directed to curb waste and incentivize high value care.  Hospital chargemaster prices are being criticized for their lack of transparency, and are also potential targets for cost savings.   Physician fees for surgical procedures are similarly scrutinized.  To better understand general surgery as a practice, we analyzed financial data of the Medicare Fee for Service program and its relationship to provider characteristics and patient demographics.

Methods:
Using the Medicare Provider Fee-For-Service Utilization and Payment Data Public Use Files from 2012-2015, we identified providers who billed for common general surgical operations, including appendectomies, cholecystectomies, colectomies, hernia repair, and small bowel resection.  Markup ratios, defined as the amount charged divided by the amount allowed by Medicare, were calculated.  Provider zip codes were matched to census data from the 2011-2015 American Community Survey.  Provider and patient demographic data were obtained and compared to markup ratios.

Results:
Male surgeons performed the majority of general surgical operations (89.3%) in comparison to females (4.6%) and ambulatory surgical centers (6.1%).  Females and ASC’s consistently increased their market share annually to a peak of 6.0% and 6.7% in 2015.  This trend was most dramatic in hernia repairs, where women increased their market share by 77% from 2012 to 2015.  Colorectal surgeons also increased their share of cases from 46.1% to 52.0% in the same time period.  Billing practices did not vary between male and female surgeons (3.71 vs 3.70, p=0.961), while ASC’s billed at higher markup ratios for all procedures (4.80 vs 3.71, p<.001).  Markup ratios were highest at both ends of the income spectrum (3.6 and 5.49), and lowest at the 50th percentile (3.33, p<.001).  Markup ratios were highest in populations with the most minorities (4.05 for Latinos and 4.3 for Asians, respectively), and were lowest in neighborhoods that were predominantly White (3.32).  Areas with more than 30% uninsured had higher markup ratios (4.28).  Markup ratios decreased as the proportion of publically insured patients increased (5.73 in 0-10% versus 2.92 in 75-100% uninsured).

Conclusion:
General surgery is a rapidly changing, yet imbalanced field of medicine.  While male surgeons still perform the majority of cases, females, ASC’s, and specialists claim a larger bite of market share every year.  Though billing practices do not vary between males and females, ASC’s consistently bill more than individual surgeons.  Finally, providers appear to adjust charges based on patient socioeconomic demographics such as age, race, insurance status and income.  These patterns may reflect a combination of maximizing revenue by capitalizing on wealth, while charging higher prices to in areas at higher risk of nonpayment.
 

47.20 Conversion Disorder Causing Prolonged Hospitalization after Incisional Hernia Repair

Posted on January 18, 2018

S. Markowiak1, S. Perz2, R. Daniel3, B. Moloney3, O. Ekwenna2, J. Ortiz1  1University Of Toledo,Department Of Surgery,Toledo, OHIO, USA 2University Of Toledo,Department Of Urology,Toledo, OHIO, USA 3University Of Toledo,Department Of Psychiatry,Toledo, OHIO, USA

Introduction:

Altered mental status following surgical procedures is a relatively common phenomenon and can have many different etiologies including metabolic, infectious, neurologic and psychologic causes. A thorough evaluation of all possible etiologies is necessary to adequately treat the patient and prevent further comorbidities. Introduction:

Methods:
Case Report.

Results:
A 66-year-old man with a history of bipolar disorder underwent repair of an incision hernia at the site of a previous renal transplant. He did well initially, but on post-operative day three he had become significantly more lethargic. His interactions with his surroundings quickly declined until he was in a catatonic state. He was evaluated in the emergency department and initially admitted to a psychiatric hospital. On post-operative day seven he was not taking anything orally. He was transferred to the hospital for enteric feeds, medication administration and medical work-up. His infectious disease, metabolic and neurologic evaluations revealed no cause for his mental status. His mental status was attributed to a conversion disorder associated with his history of bipolar depression in response to the physiologic stress of surgery. Medical therapy was unsuccessful and he was ultimately treated with electroconvulsive therapy which led to substantial improvement and return to normal function.

Conclusion:
Psychiatric disease can lead to significant post-operative morbidity. It is important to evaluate all possible causes of altered mental status before attributing symptoms entirely to psychiatric causes. Early involvement of all relevant specialists can lead to early and aggressive treatment and limit comorbidities associated with prolonged hospital stay.
 

47.16 Healthcare Reform in Maryland: The Influence of Global Budgets on Emergent Ventral Hernia Repair

Posted on January 18, 2018

S. R. Kaslow1, M. Stem2, J. K. Canner1, G. L. Adrales2  1Johns Hopkins Surgery Center For Outcomes Research,Department Of Surgery,Baltimore, MD, USA 2Johns Hopkins School Of Medicine,Baltimore, MD, USA

Introduction

In January 2014 Maryland enacted a Global Budget Revenue (GBR) system in which all payers and hospitals are connected in a fixed payment capitated system to improve access to preventive care and care coordination. Many determinants of health addressed by GBR are also predictors of emergent ventral hernia repair (VHR). We aimed 1) to investigate associations between GBR implementation and the proportion of VHRs performed emergently, and 2) to study how implementation impacted risk factors of emergent VHR.

Methods

Patients with a diagnosis of ventral hernia who underwent surgical repair were identified in the Maryland Health Services Cost Review Commission patient-level case mix data from 2011 through Q3 2015, excluding trauma diagnoses. Patients were stratified into two groups: pre- and post-GBR implementation. Multivariable logistic regression was used to identify risk factors for emergent VHR performed pre- and post-implementation and to assess the impact of GBR on emergent cases.

Results

A total of 8,938 patients were identified. 3,770 (42.2%) patients underwent an emergent procedure: 2,517 (68.0%) pre- and 1,253 (33.9%) post-implementation. The proportion of emergent VHRs remained the same after implementation (33.2% in 2011-2013 vs. 33.6% in 2014-2015, p=0.71). Adjusted analysis showed that implementation had no significant impact on requiring an emergent procedure (OR 1.01, 95% CI 0.92-1.11, p=0.81). The patient risk factors for emergent VHR (age ≥75, Black race, Charlson Comorbidity Index, insurance) did not change dramatically after GBR implementation. However, a Charlson score of 2 or higher was associated with emergent VHR before implementation (Score 0: Ref; Score 2: OR 1.27, 95% CI 1.07-1.52, p=0.01; score ≥3: OR 1.30, 95% CI 1.10-1.53, p<0.001), while a score of 1 or higher was associated with emergent VHR after implementation (score 1: OR 1.32, 95% CI 1.09-1.60, p=0.01; score 2: OR 1.35, 95% CI 1.06-1.72, p=0.02; score ≥3: OR 1.75, 95% CI 1.38-2.20, p<0.001). Additionally, median income in the highest two quartiles had a lower risk of emergent VHR before implementation (1st quartile: Ref; 3rd quartile: OR 0.68, 95% CI 0.58-0.79, p<0.001; 4th quartile: OR 0.74, 95% CI 0.63-0.87, p<0.001); this association was not statistically significant in the post-implementation period.

Conclusion

GBR implementation had no significant impact on emergent VHR or the factors associated with emergent VHR. However, lower risk patients (i.e. lower Charlson Comorbidity score) were more likely to undergo emergent VHR after GBR implementation which may be due to surgical trends other than GBR such as watchful waiting. While higher income was protective against emergent VHR before implementation, the association between income and emergent VHR was not present after GBR implementation. Additional study is needed to determine if GBR improved access to care and lessened the impact of income or if there were other contributing factors.

47.17 Inpatient Opioid Prescription Trends Among Laparoscopic Surgeons at a Mid-Atlantic Medical Center

Posted on January 18, 2018

Z. Sanford1, A. Broda1, A. Weltz1, I. Belyansky1  1Anne Arundel Medical Center,Department Of Surgery,Annapolis, MD, USA

Introduction:
Unintentional poisoning has become the leading cause of injury-related fatalities in the United States and many of these are directly from prescription opioids.  A lack of guidelines for opioid prescription in surgical management may lead to variations in amount of medication prescribed to patients.

Methods:
A retrospective review focusing on differences in prescribing habits of surgeons as a function of case frequency was performed for all patients undergoing laparoscopic cholecystectomy and laparoscopic inguinal hernia repair from January 2014 to June 2017.  Inpatient medication was adjusted to Morphine Milligram Equivalents (MME).

Results:
In a cohort of twenty-two surgeons, twenty-two performed laparoscopic cholecystectomy and ten performed laparoscopic inguinal hernia repair.  Patients undergoing laparoscopic cholecystectomy (n = 1,890) presented with a mean age, BMI, and ASA score of 50.9 years, 31.4 kg/m2, and 2.3, respectively, with a procedure time of 57.0 minutes, hospital LOS of 2.2 days, and opioid pain prescription of 12.6 MME per day.  14.5% of patients did not receive any opioid pain control and daily prescribed doses ranged from 0-521.1 MME.  Patients undergoing laparoscopic inguinal hernia repair (n = 821) presented with a mean age, BMI, and ASA score of 57.0 years, 27.0 kg/m2, and 2.1, respectively, with a procedure time of 61.6 minutes, hospital LOS of 1.1 days, and opioid pain control of 6.6 MME per day.  30.8% of patients did not receive any opioid pain control and daily prescribed doses ranged from 0-91.4 MME.  In both the laparoscopic cholecystectomy (p < 0.0001) and laparoscopic inguinal hernia repair (p < 0.0064) subgroups surgeons demonstrated consistent prescription patterns individually within their own practice however there were significant differences among inter-surgeon prescribing patterns of postoperative opioid pain control.

Conclusion:
Prescribing habits of MME are based solely on personal preference and the professional discretion of prescribing physicians resulting in significant inter-surgeon variability in daily-prescribed MME after laparoscopic cholecystectomy and laparoscopic inguinal hernia.
 

47.14 Decision Making in Advanced Surgical Illness: The Surgeons Perspective in Shared Decision Making

Posted on January 18, 2018

R. S. Morris1, J. Ruck2, A. Conca-Cheng2, T. Smith2, T. Carver1, F. Johnston2  1Medical College Of Wisconsin,Surgery,Milwaukee, WI, USA 2Johns Hopkins University School Of Medicine,Surgery,Baltimore, MD, USA

Introduction:  While surgical patients increasingly have more comorbid disorders and older age, surgeons face difficult decisions in emergent situations. Little is known about surgeon perceptions on the shared decision making process in these urgent settings.

Methods:  Twenty semi-structured interviews were conducted with practicing surgeons at two large academic medical centers. Thirteen questions and two case vignettes were used to assess participant perceptions, considerations when deciding to offer surgery and communication patterns with patients and families.

Results:Thematic analysis revealed six major themes and numerous subthemes related to end-of-life decision-making for critically ill patients: responsibility for the decision to operate, futility, surgeon judgment, surgeon introspection, pressure to operate and costs of surgery. Futility was universally reported as a contraindication to surgical intervention. However, an inability to definitively declare futility led some participants to emphasize patient self-determined risk-benefit analysis to determine whether to proceed with surgical intervention. Other participants who felt their gestalt about futility was reliable described greater comfort communicating to a patient that their condition was not amenable to surgery and reserved the right to refuse surgical intervention. Most participants desire objective metrics to determine risk and futility in order to more clearly communicate with patients and families, and perhaps temper the pressure to operate from external sources. 

Conclusion:Due to external pressures and uncertainty, some providers err on the side of continuing care despite suspected futility. Surgeons with greater experience and those who report more institutional support of their decisions are often more able to withstand external pressures, feel confident in their assessments of futility, and guide patients and their families away from futile interventions. Greater support from colleagues, institutional culture, research literature, and objective measures of futility can support surgeons in shared decision making and providing the best care for their patients. 

 

47.03 Justifying Our Decisions About Surgical Technique: Evidence from Coaching Conversations

Posted on January 18, 2018

A. E. Kanters1, S. P. Shubeck1, G. Sandhu1, C. C. Greenberg2, J. B. Dimick1  1University Of Michigan,General Surgery,Ann Arbor, MI, USA 2University Of Wisconsin,Madison, WI, USA

Introduction: Although the quality of an operation depends heavily on operative technique, there’s very little evidence illuminating how surgeons arrive at their intraoperative decisions. Surgical training largely follows an apprenticeship model. This model of learning has the potential to perpetuate surgical knowledge grounded in anecdote rather than surgical literature. The objective of this study was to determine the extent to which practicing surgeons justify their technical decisions based on their experience or based on evidence. 

Methods: This qualitative study evaluated 10 video coaching conversations between 20 bariatric surgeons at the Michigan Bariatric Surgery Collaborative meeting in October 2015. Using grounded theory approach, the coaching dyads were coded in an iterative process with comparative analysis in order to identify emerging themes. We focused on how participants justified specific surgical techniques and decisions as these topics were a common theme identified in each of the coaching transcripts. 

Results: Three major themes emerged during analysis. (1) Most commonly, we found individuals reported modifications in surgical technique after a particularly negative postoperative complication for a single patient. For example, one surgeon reported, “Why did this leak? I had no reason…so that’s when I started to just say, ‘I’m just going to over sew everybody.’” (2) Alternatively, participants were noted to defend use of certain techniques or surgical decisions based on their perceived expert opinion of others. For example, individual surgeons often refer to how they were trained or how they witnessed another surgeon in the field perform a procedure as their impetus for modifying their own technique. (3) Finally, there was a notable lack of referring to evidence in surgical literature or educational programming as a motivation for changing surgical technique.

Conclusion: In this qualitative analysis of coaching conversations we found that practicing surgeons most often justify their surgical decisions with anecdotal evidence and “lessons learned”, rather than deferring to surgical literature to motivate their behaviors. This either represents a lack of evidence or poor uptake of existing data. 
 

39.09 Better ABSITE Performance with Increased Operative Case Load During Surgical Residency

Posted on January 18, 2018

A. R. Marcadis1, T. Spencer1, D. Sleeman1, O. C. Velazquez1, J. I. Lew1  1University Of Miami,DeWitt Daughtry Family Department Of Surgery,Miami, FL, USA

Introduction: Common measures of evaluating surgical resident progression during General Surgery residency include American Board of Surgery In-Training Exam (ABSITE) scores and operative case logs. It remains unknown, however, if there is an association between operative case numbers and resident ABSITE performance. This study evaluates the relationship between operative cases performed and ABSITE scores at both the junior and chief resident levels. 

Methods: A retrospective review of ABSITE scores and operative case logs was performed for categorical General Surgery residents at a single institution at the junior (post graduate year [PGY]-2, n=45, from 2009-2017) and chief (PGY-5, n=19, from 2014-2016) levels. For each surgical resident, total number of operative cases logged (major and minor) from the start of their PGY-1 year until the end of either their 2nd or 5th year was calculated and compared to their ABSITE percentile score for that corresponding year using unpaired t-test and linear regression. Outliers with operative cases logged >3 standard deviations from the mean were excluded.

Results:  There was a linear relationship between total number of operative cases logged and ABSITE percentile score for surgical residents at both the junior (slope, m = 1.295) and chief resident (m = 6.109) levels, with a higher number of total operative cases logged being significantly associated with higher ABSITE percentile scores. For both junior and chief residents, there was a statistically significant difference in average number of operative cases logged between those with ABSITE scores below the 50th percentile and those with scores above the 50th percentile (junior cases, 311 vs. 370, p<0.05;  and chief cases, 1352 vs. 1683, p<0.05), respectively.

Conclusion: Surgical residents who perform higher numbers of operative cases do significantly better on the ABSITE than their peers with lower operative case numbers. This association may be due to increased clinical experience, exposure to pathology and/or individual surgical resident motivation.

 

39.10 Not All Operative Experiences Are Created Equal: 18 Year Analysis of a Single Center’s Case Logs

Posted on January 18, 2018

A. R. Cortez1, V. K. Dhar1, J. J. Sussman1, T. A. Pritts1, M. J. Edwards1, R. Quillin2  1University Of Cincinnati,Department Of Surgery,Cincinnati, OH, USA 2Columbia University College Of Physicians And Surgeons,Center For Liver Disease And Transplantation,New York, NY, USA

Introduction: As surgical education continues to evolve, so too does the need for surgical educators to better understand how residents learn. Previous analyses of national Accreditation Council for Graduate Medical Education (ACGME) operative log reports have shown that total operative volumes for graduating general surgery residents have remained stable over time, despite changes in duty hour restrictions. However, variability in subspecialty operative volume and its impact on resident training experience has not been well studied. 

Methods: ACGME operative log data from 1999 to 2016 for a single academic general surgery residency program were examined. All residents completed the Kolb Learning Style Inventory during their training and were subsequently classified as action-based or observation-based learners. Statistical analyses were performed using Wilcoxon rank-sum test, Chi-square test and linear regression analysis. A p-value <0.05 was considered to be statistically significant.

 

Results: Over the 18-year study period, 106 general surgery residents graduated from our training program. There were 92 action-based learners (87%) and 14 observation-based learners (13%). These two groups were similar in terms of race, sex and having a dedicated research experience (all p=NS). Linear regression analysis showed no change in total major cases during the 18-year study period (p=0.38). Subcategory analysis, however, revealed a significant increase in operative volume upon graduation in the following defined categories: skin, soft tissue and breast (+2.8 cases/year); alimentary tract (+10.1 cases/year); abdomen (+15.4 cases/year); endoscopy (+3.0 cases/year) and laparoscopy (+10.9 cases/year, all p<0.05). Conversely, a decrease was seen in the following defined categories: liver (-0.44 cases/year), vascular (-1.1 cases/year) and endocrine (-0.5 cases/year, all p<0.05). Learning style analysis revealed that action-based learners completed significantly more cases than observation-based learners in each of the domains in which operative volume increased (Figure).

Conclusions: While the total operative volume of graduates at our center has remained stable over the past 18 years, the operative experience of general surgery residents has become more narrowed toward a less subspecialized general surgery experience. These shifts may be disproportionally impacting trainees, as observation-based learners were found to operate less than action-based learners in select categories. Residency programs should therefore incorporate methods such as learning style assessment to identify residents at risk of having a suboptimal training experience.

39.05 Narrowing of Surgical Resident Operative Experience: 27 Year Analysis of National ACGME Case Logs

Posted on January 18, 2018

A. R. Cortez1, G. D. Katsaros2, V. K. Dhar1, F. Drake3, T. A. Pritts1, J. J. Sussman1, M. J. Edwards1, R. Quillin4  1University Of Cincinnati,Department Of Surgery,Cincinnati, OH, USA 2University Of Cincinnati,College Of Medicine,Cincinnati, OH, USA 3Boston University,Department Of Surgery,Boston, MA, USA 4Columbia University College Of Physicians And Surgeons,Center For Liver Disease And Transplantation,New York, NY, USA

Introduction: Operative volume is traditionally used to assess graduating trainees’ readiness for independent practice. Although studies have shown that overall operative volume has remained stable despite implementation of duty hour restrictions, subcategory analyses have revealed shifts in the diversity of resident operative experience. Understanding these differences in operative trends may allow educators to better appreciate the impact of the current training environment on the competency of graduating surgical residents.

Methods: Accreditation Council for Graduate Medical Education (ACGME) national operative log reports from 1990 to 2016 were reviewed. Statistical analysis was performed using linear regression analysis. A p-value <0.05 was considered to be statistically significant.

Results: ACGME operative log data was analyzed for 27,851 graduating general surgery residents from 1990 to 2016. During this period, the number of residents increased (+4.87 residents/year) while the number of programs decreased (-1.33 programs/year, all p<0.05), such that each program had on average one more resident at the end of the study period. Linear regression analysis revealed no change in total major cases during the 27-year study period (p=0.54). Subcategory analysis, however, showed an increase in total major cases upon graduation in the following categories: skin and soft tissue (+1.60 cases/year), alimentary tract (+2.6 cases/year), abdomen (+4.01 cases/year) and endoscopy (+0.71 cases/year, all p<0.05). There was a concurrent decrease in breast (-0.54 cases/year), pediatrics (-0.87 cases/year) and trauma (-1.73 cases/year, all p<0.05). During this time, first assistant operative volume decreased markedly (-10.2 cases/year, p<0.05). Residents also completed fewer cases during their chief year (-1.77 cases/year), operated more during their non-chief years (+3.1 cases/year) and taught fewer operations over the course of their residency (-1.9 cases/year, all p<0.05). A decrease in overall operative volume variability (-6.77 cases/year, p<0.05) was seen as a result of a 3.3 cases/year decrease for the 90th percentile and 6.6 cases/year increase for the 10th percentile of total major cases converging toward the median (Figure).

Conclusion: While total major cases upon graduation have remained stable over the past 27 years, the operative experience of general surgery residents has narrowed significantly. Residents appear to be operating more in the early years of training, performing fewer first assist cases and operating less often as teaching assistants. Surgical educators must look beyond total case numbers and be aware of these subtle shifts to ensure all residents achieve technical competency upon graduation.

39.06 Gender and Faculty Entrustment: An Objective Intraoperative Measurement of Entrustment Behaviors

Posted on January 18, 2018

J. A. Thompson-Burdine1, D. C. Sutzko1, V. C. Nikolian1, A. Boniakowski1, P. E. Georgoff1, K. A. Prabhu1, N. Matusko1, R. M. Minter2, G. Sandhu1  1University Of Michigan,Department Of Surgery,Ann Arbor, MI, USA 2University Of Texas Southwestern Medical Center,Department Of Surgery,Dallas, TX, USA

Introduction: Optimizing intraoperative education is critical for development of autonomous residents. Faculty entrustment decisions determine the degree to which a resident gains intraoperative responsibility. Entrustment and entrustability are part of a dual educational responsibility, however little empirical evidence exists evaluating how gender influences faculty-resident entrustment decisions in the operating room. Studies involving perception-based autonomy measurement tools report gender inequities. We sought to assess gender dynamics of entrustment behaviors using OpTrust, a 3rd-party objective measurement tool.

Methods: From September 2015 – June 2017, researchers observed elective surgical cases at the University of Michigan and rated entrustment behaviors using OpTrust, a validated tool designed to assess progressive entrustment in the operating room (OR). Purposeful sampling was used to generate variation in operation type, case difficulty, faculty-resident pairings, faculty experience, and resident training level.

Results: 56 faculty and 73 residents were observed across 225 surgical cases from four surgical specialties: general, plastic, thoracic, and vascular surgery. Independent samples t-tests did not detect a significant difference in faculty entrustment scores by resident gender (F=2.54 vs M=2.35, p=.117). Furthermore, no difference was found in resident entrustability scores between women and men (2.32 vs 2.22, p=.393).

Conclusion: Using OpTrust scores, we found that gender does not appear to influence faculty entrustment in the OR. Faculty entrustment scores for women and men residents are consistent. This indicates that during the intraoperative interaction, faculty are not extending entrustment or opportunities for autonomy differently based on gender. The difference between 3rd-party objective entrustment measurement and perception-based autonomy measurements may be attributed to factors outside of the discrete intraoperative interaction that may contribute to gender bias and confound self-assessment. While it is encouraging that faculty entrustment behaviors in the operating room are impartial, future research is needed to identify and measure perioperative elements that inform resident autonomy and which may contribute to gender inequities for residents.

 

39.02 Blind spots in the feedback process – exploring trainee and faculty perceptions

Posted on January 18, 2018

S. Scarlet1, A. Reiter1, J. Crowner1, M. O. Meyers1  1University Of North Carolina At Chapel Hill,Chapel Hill, NC, USA

Introduction:  As surgical training continues to evolve with regard to operative experience and autonomy, the role of timely, high quality feedback has become increasingly important.  Our aim was to characterize trainee and faculty perceptions regarding feedback.     

Methods:  Complementary surveys to characterize trainee and faculty perception of feedback regarding procedural skills using a 5-point Likert scale were distributed to 79 surgical trainees and 70 faculty from a single institution. Statistical analysis was completed using chi-squared testing. 

Results: 35 trainees (17 women) and 26 faculty (8 women) completed the survey; overall response rate was 40.9%. 100% of trainees and faculty agreed/strongly agreed that feedback regarding technical skills is valuable.  However, 51% of residents were dissatisfied with feedback overall. 36% of trainees reported dissatisfaction with feedback on technical skills, while faculty perceived that 8% of trainees were dissatisfied with the feedback they received (p=0.01). 6% of trainees reported receiving feedback following a procedure always/most of the time, whereas 73% of faculty reported delivering feedback on technical skills always/most of the time (p<0.001). 100% of faculty reported delivering feedback when trainees utilized poor technique, but only 64% of residents felt they had received feedback for poor technique (p<0.001). Similarly, 80% of faculty reported giving feedback when residents demonstrated good technique, whereas only 21% of residents reported receiving feedback in this circumstance (p<0.001). 

Conclusion: While both residents and faculty agreed that feedback is valuable, a disconnect exists between perceptions regarding its timing, content, and delivery. Acknowledging differing perceptions of feedback is necessary in order to enhance the quality of the feedback process and cultivate a more optimal training environment. Further study is required to determine how to best reduce the significant differences we observed in perceptions of feedback held by residents and faculty. 

 

39.03 Is the operative autonomy granted to a resident consistent with the operative performance quality?

Posted on January 18, 2018

J. P. Fryer4, B. C. George1, B. D. Bohnen2, S. L. Meyerson4, M. C. Schuller4, A. H. Meier5, L. Torbeck3, S. P. Mandell6, J. T. Mullen2, D. S. Smink7, J. G. Chipman8, E. D. Auyang9, K. P. Terhune10, P. E. Wise11, J. N. Choi3, E. F. Foley13, M. A. Choti12, C. Are15, N. J. Soper4, K. D. Lillemoe2, J. B. Zwischenberger14, G. L. Dunnington3, R. G. Williams3  1University Of Michigan,Ann Arbor, MI, USA 2Massachusetts General Hospital,Boston, MA, USA 3Indiana University School Of Medicine,Indianapolis, IN, USA 4Northwestern University,Department Of Surgery,Chicago, IL, USA 5State University Of New York Upstate Medical University,Syracuse, NY, USA 6University Of Washington,Seattle, WA, USA 7Brigham And Women’s Hospital,Boston, MA, USA 8University Of Minnesota,Minneapolis, MN, USA 9University Of New Mexico HSC,Albuquerque, NM, USA 10Vanderbilt University Medical Center,Nashville, TN, USA 11Washington University,St. Louis, MO, USA 12University Of Texas Southwestern Medical Center,Dallas, TX, USA 13University Of Wisconsin,Madison, WI, USA 14University Of Kentucky,Lexington, KY, USA 15University Of Nebraska College Of Medicine,Omaha, NE, USA

Introduction. Surgical residency training should produce surgeons capable of performing core procedures competently and independently. As residents’ operative performances improve, faculty should allow greater autonomy. In this study we seek to identify and define situations where the operative autonomy levels granted to residents was inconsistent with their operative performance.

Methods.  Surgical faculty provided operative performance ratings for PGY1-5 residents from 14 U.S. general surgery residency programs using the SIMPL smartphone app. For each procedure the supervising surgeon assessed the resident’s operative performance and indicated the level of autonomy that the resident was granted during that procedure. Performance was assessed using an ordinal operative performance scale and autonomy was characterized using the Zwisch autonomy scale. Concordance between performance and autonomy scores was defined as concurrent scores of either “practice ready (performance) or above and meaningful autonomy” (Zwisch) [aka PR/MA] or “not practice ready or above and not meaningfully autonomous” [NPR/NMA]. Discordant scores were “practice ready or above and not meaningfully autonomous” (PR/NMA) as well as “not practice ready or above and meaningfully autonomous” (NPR/MA). The supervising surgeon also indicated the patient-related complexity of the case. Multiple variables were investigated to determine their impact on resident operative autonomy including: resident performance, PGY level, patient-related case complexity, procedure-related complexity, procedure frequency, core vs. specialty procedures.

Results. During the study period 10964 SIMPL assessments that included both a performance score and an autonomy score were collected from 493 different surgeons assessing 615 different residents. 80% of assessments were concordant; including 39% rated as PR/MA and 41% as NPR/NMA. Of the 20% of discordant assessments, most (14.4%) were NPR/MA while the remaining 5.6% were PR/NMA. NPR/MA was the predominant discordant rating in PGY1-4 residents. In PGY5 residents PR/NMA ratings (8.9%) were slightly more frequent than NPR/MA ratings (8.2%). All but 7 surgical attendings (1.4%) provided opportunities for meaningful autonomy on at least one occasion. High volume and easy cases were more frequently performed under meaningfully autonomous circumstances. Operative performance quality accounted for 74% of the variance in the faculty surgeons’ decisions about the level of autonomy allowed (F=341.84; p<0.05).

Conclusions. Faculty autonomy granted to surgical residents was concordant with resident performance in most cases. When discordant, faculty most commonly provided meaningful autonomy when the performance was less than practice ready, a combination to be expected on occasion during training. Few surgical attending surgeons provided no opportunities for autonomous resident operative performance.

39.04 The Influence of Gender and Rank on the Resident Evaluation Process

Posted on January 18, 2018

L. Theiss1, B. Corey1, H. Chen1, R. Dabal1,2  1University Of Alabama at Birmingham,Birmingham, Alabama, USA 2Children’s Of Alabama,Birmingham, ALABAMA, USA

Introduction: The progress of general surgery residents in the United States is measured both by subjective and objective measures. Peer-to-peer, faculty-to-resident, and student-to-resident evaluations play an important role in measuring resident progress and providing constructive feedback. However, bias is unavoidable in the evaluation process. We sought to determine whether gender or rank had an impact on the way that general surgery residents were evaluated by medical students in skill-independent areas such as integrity and honesty.

Methods: Data was extracted from 2323 medical student evaluations of general surgery residents at a single institution over five years. Scores from five evaluation questions relating to emotional intelligence, patient care, and professionalism were collected. Evaluation responses range from 1-10 for each question. Scores were compared between male and female residents and between PGY 1 and PGY 2-5 residents. Univariate analysis was performed.

Results: In our cohort of 2323 general surgery resident evaluations, 729 (31.4%) of the subjects were female and 1594 (68.6%) were male. 473 (20.4%) were PGY 1 and 1850 (79.6%) were PGY 2-5. Out of 10 possible points, median evaluation score ranged from 8.10-8.43 for the group. Median scores for female residents were as follows: 8.15, 8.26, 8.29, 8.04, 8.36. Median scores for male residents were: 8.39, 8.43, 8.42, 8.13, 8.46. Male residents received higher scores on all five questions related to emotional intelligence and professionalism (p <0.0003 for all questions). There was no statistically significant difference in scores between PGY 1 residents and PGY 2-5 residents.

Conclusion: When evaluated by medical students, female general surgery residents scored lower than male residents in areas relating to professionalism and psychosocial elements of patient care. Scores did not vary based on resident rank, suggesting that gender, rather than resident experience, influenced subjective evaluation. These data reflect the larger issue of gender bias in surgery. As the number of women in surgery continues to grow, further investigation is needed to better understand and draw attention to the inherent biases and expectations that females face in surgical specialties.
 

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