40.01 Are Surgical Residency and Parenthood Compatible?

Posted on December 22, 2014

C. Kin1, M. Esquivel1, C. Mueller1  1Stanford University,Surgery,Palo Alto, CA, USA

Introduction:  Surgical residents commit to a minimum of five years of intensive training during their prime reproductive years. Our hypothesis is that while all surgical residents face significant barriers that prevent them from starting families, there are gender differences in their attitudes towards having children. The aim of this study is to identify the concerns and challenges of surgical residents with regards to having children. 

Methods:  We administered a 32-question anonymous online survey to all residents in general surgery and surgical subspecialties at a tertiary care academic medical institution. Participants were compensated with a $10 gift certificate. Chi-square and Fisher’s exact tests were used to determine if there was a significant difference between groups, and p<0.05 was considered significant.

Results: Of 171 surveys sent, 83 were started and 80 completed; 53% of respondents were men and 46% were women. Men and women were similar in age distribution (54% aged 31-35, 41% aged 26-30), as well as proportions in long-term relationships (75% vs 79%) and proportions with children (18% vs 21%), with most parents having one child. Male and female residents are similar in their concerns that they had inadequate time, money, and childcare resources to have children.(Table 1) Women are more likely to worry that having children would negatively affect the way they were perceived professionally (55% vs 16%, p=0.0002), make them a burden on their colleagues (84% vs 39%, p<0.0001), and negatively impact their future careers (53% vs 23%, p=0.005). Women are also more likely to believe that there is no optimal professional time to have a child (74% vs 43%, p=0.005). The majority of childless residents agreed that they are deferring having children because of their jobs, and 73% feel anxious when they think about having children. Childless female residents are more likely to be worried about the possibility of not ever having children (77% vs 44%, p=0.008). Only a third of residents have discussed the topic of having children with a mentor, and of those who have not discussed it, women are more likely than men to want to have that discussion with a mentor (56% vs 26%, p=0.04). 

Conclusion: The scarce financial resources and time commitment inherent to surgical training are barriers that prevent many residents from starting families and pose great difficulties for residents who do have children. Female surgical trainees are particularly worried about work-family conflicts. Residency programs and mentors should be aware of these stressors and creative solutions are needed to promote the welfare of their surgical trainees. 

 

40.02 Practice Administration Training Needs of Recent General Surgery Graduates

Posted on December 22, 2014

M. Klingensmith1, T. H. Cogbill3, K. Samonte2, A. Jones2, M. Malangoni2  1Washington University,Surgery,St. Louis, MO, USA 2American Board Of Surgery Inc,Philadelphia, PA, USA 3Gundersen Health System,Surgery,LaCrosse, WI, USA

Introduction:  Practice administration education and experience during surgery residency is limited and highly variable among residency programs. To gain understanding into the current status of practice administration training, a survey of recent General Surgery residency (GS) graduates was undertaken. This was compared to results from a survey of GS program directors (PD).

Methods:  All US allopathic GS   graduates who completed residency  from 2009- 2013 (n= 5194) were anonymously surveyed by the American Board of Surgery (ABS) to assess opinions  regarding their desire to have received more instruction and experience  during residency in the following practice administration areas: coding, contract negotiations, practice management, insurance billing, billing the uninsured, liability, insurance for one’s own practice,  and retirement planning. Surveys were distributed by mail in November 2013 with up to two follow up mailings to non-respondents.  General Surgeons were defined as those who did not pursue fellowship training; specialist surgeons (SS) completed additional training following GS residency. Separately, all GS residency PDs were surveyed regarding the inclusion of practice administration education in their residency programs.

Results: There were 3354 respondents to the GS graduate survey (response rate 68%). GS comprised 876 of the total respondents (26%) with SS accounting for the remaining 74%.     The vast majority of all respondents desired more training in all areas of practice administration that were queried: coding instruction (desired by 86%), contract negotiations (84%), practice management (83%), insurance billing (82%), billing those uninsured (77%), liability (76%), insurance for one’s own practice (75%), and retirement planning (72%). There were no significant differences in the degree to which these areas of instruction were desired among graduate year cohorts, residency program type or current practice setting (academic vs community). However, GS tended to have greater desire for this training than SS in many but not all content areas queried. The GS PD survey had a response rate of 68% (171 of 252 programs). Among respondents, only 28% of programs included practice administration as part of the residency curriculum.

Conclusion: 

Despite increased accreditation and ABS requirements for GS residency programs, there is no mandate for trainees to receive practice administration education and this topic is seldom included in the curriculum.  However, such skills are highly desired and needed by program graduates in a range of practice types and  locations. This large survey of recent GS residency graduates indicates a clear and desired need for an improved curriculum and experience in practice administration topics during residency. Steps should be taken to address this educational gap.

 

 

40.03 YouTube is the Most Frequently Used Educational Video Source for Surgical Preparation

Posted on December 22, 2014

A. K. Rapp1, M. G. Healy2, M. E. Charlton3, M. E. Rosenbaum4, M. R. Kapadia2  1University Of Iowa,Carver College Of Medicine,Iowa City, IA, USA 2University Of Iowa,Department Of Surgery,Iowa City, IA, USA 3University Of Iowa,College Of Public Health,Iowa City, IA, USA 4University Of Iowa,Department Of Family Medicine,Iowa City, IA, USA

Introduction: In this technology-driven era, medical professionals have instant access to videos of surgical procedures. In addition to reading and peer consultation, a plethora of online videos are available to surgeons preparing for surgical cases. The purpose of this study was to evaluate the surgical preparation methods of medical students, residents, and attending surgeons, with special attention to video usage.

Methods: Anonymous paper surveys were distributed to fourth-year medical students pursuing general surgery, general surgery residents, and attending surgeons in the Department of Surgery at a single academic medical center following IRB approval. Information collected included demographics and surgical preparation methods, focusing on video usage. Participants were questioned regarding frequency and helpfulness of video usage; video sources most utilized; and preferred preparation methods between videos, reading, and peer consultation. Chi-square and Fisher’s exact tests were used to compare learner (medical student and resident) and attending responses.

Results: The overall response rate was 91%, which included 42 leaners and 36 attendings. Residents (n=33) from each clinical year (1-5) were represented, and attending experience ranged from 1-36 years (mean=11 years). 90% of all respondents reported using videos for surgical preparation, with no significant difference between learners (95%) and attendings (83%). The mean video helpfulness rating was 3.5 (range 1-5; 1=not helpful, 5=very helpful). Of respondents who perform laparoscopic procedures (n=60), all used videos, whereas only 55% of those who do not perform laparoscopic procedures used videos (p<0.0001). Regarding surgical preparation methods overall, most learners and attendings reported reading (63% versus 78%, p=NS) and some reported watching videos (64% versus 44%, p=NS); however, attendings more often utilized peer consultation compared to learners (50% versus 24%, p<0.02).

Among the 90% of respondents that reported using videos, the most commonly utilized video source was YouTube (86%). Learners and attendings used different video sources (see Figure): learners used YouTube and the Surgical Council on Resident Education (SCORE) Portal more frequently than attendings (YouTube: 95% versus 73%, p<0.05; SCORE: 25% versus 7%, p<0.05); however, attendings were more likely than learners to use society webpages and commercial videos (society: 67% versus 38%, p<0.03; commercial: 27% versus 5%, p<0.02).

Conclusions: The majority of respondents reported using videos to prepare for surgery and YouTube is the preferred source. Posting surgical videos to YouTube may allow for maximal access to learners who are preparing for surgical cases.

 

40.04 The Emergence of Video Technology as an Important Adjunct to Surgical Education

Posted on December 22, 2014

K. M. McKendy1, L. Lee1, J. R. Grushka1, A. N. Beckett1, K. A. Khwaja1, P. Fata1, T. S. Razek1, D. L. Deckelbaum1  1McGill University,General Surgery / Surgery,Montreal, QC, Canada

Introduction:

When preparing to perform a case in the operating room, surgical residents often review the steps of procedures using surgical atlases.  Videos of surgical procedures are an emerging teaching modality.  While video footage is more readily available for laparoscopic cases, high quality videos of open surgical cases are scarce.  Moreover, many videos are created without using rigorous methodology.  The aim of our study was to validate the use of instructional videos as an educational tool in surgery.  We began by looking at open tracheostomy, since this procedure is relatively straightforward and frequently performed at our institution.

Methods:

Cognitive task analysis (CTA) was used to elaborate a list of the key steps of an open tracheostomy.  Six experts were interviewed and asked to describe how they perform an open tracheostomy.  The interviews were transcribed and analyzed, and a list of the 10 key steps and each of their sub-steps was elaborated.  The experts were then asked to rate the importance of each sub-step using a Likert scale.  An instructional video of an open tracheostomy case was then created, underscoring the steps and decision-making points emphasized by the expert panel using CTA.  To establish proof of concept of the utility of these instructional videos, a pilot study was conducted with PGY-1 and 2 surgical residents.  The residents were randomized to either view the video or read a text of the video narration, and then tested on their knowledge of the critical steps of the procedure. Critical steps were identified through CTA using a weighted scale.  Results were analyzed using an independent sample t-test.  For additional feedback on the quality and utility of the video, those randomized to the video group were subsequently asked to complete a questionnaire on its educational value.

Results:

64 PGY-1 and 2 surgical residents from all surgical subspecialties were enrolled in the study.  Of these, 40 completed the test: 20 residents from the video group and 20 from the text group.  While there was no significant difference between the average scores of the video and text group, 93% of residents who were randomized to the video group agreed that the video was a useful learning tool and that it helped prepare them for the operating room.  In addition, 92% agreed or strongly agreed that they would watch the video rather than reviewing the content in a textbook, and 100% felt that their knowledge of relevant anatomy had improved with the video.

Conclusion:

This study illustrates the use of CTA in the creation of an instructional surgical video on open tracheostomy.  The results of this pilot study suggest that surgical videos are an excellent adjunct to the educational armamentarium of surgical trainees.

40.05 Working at home: Results from a multi-center survey of surgery & internal medicine residents

Posted on December 22, 2014

C. Thiessen1, L. S. Lehmann3, F. G. Javier5, M. J. Erlendson5, L. A. Skrip4, M. R. Mercurio2, K. A. Davis1  1Yale University School Of Medicine,Department Of Surgery,New Haven, CT, USA 2Yale University School Of Medicine,Department Of Pediatrics,New Haven, CT, USA 3Brigham And Women’s Hospital,Department Of Medicine,Boston, MA, USA 4Yale School Of Public Health,Department Of Epidemiology Of Microbial Diseases,New Haven, CT, USA 5Yale University School Of Medicine,New Haven, CT, USA

Introduction:  With the spread of electronic medical records, residents have increasing opportunities to do patient care work at home. ACGME guidance specifies that patient work at home should count toward the resident hour limits. This study evaluated the amount and type of patient care work residents report performing at home, and why they do so.

Methods:  Residents at 26 general surgery and internal medicine residency programs were invited to take an anonymous online survey about work at home and duty hours. Programs were selected to represent a range of geographic location, size, and academic status. The survey was administered in May and June 2014. When answering questions about work at home, residents were instructed to think only about patient care and to exclude time spent “studying, preparing for presentations, or doing research.” Our results were analyzed with standard descriptive statistics in SAS 9.3. We used multivariate logistic regression to determine if demographic variables including specialty and training level were associated with reporting working at home.

Results: Of 1591 contacted residents, 535 completed the survey (response rate 34%). Sixty percent of all respondents were men, 60% were Caucasian, 56% were < 30 years old, and 42% were general surgery residents. Respondent level included PGY1 (38%), PGY2 (28%), PGY3 (22%), and PGY4-5 and research years (12%). Most residents reported performing patient care work at home, but did not count this toward their duty hours (88%). Residents worked at home an average of 1-2 hours (35%), 2-5 hours (36%), 5-10 hours (14%), or >10 hours (4%) per week. Work at home included: checking lab and results (92%), reading charts to prepare for a new rotation (87%), reviewing patient vitals (75%), and talking to other residents or attendings (72%). Surgery residents also frequently reviewed charts for upcoming cases (94%) and completed operative reports (65%). Curiosity about patient outcomes (78%), desire to leave the hospital (74%), comfort (66%), and increased time with family (61%) were the most important reasons for working at home. Thirty percent of residents explicitly did work at home to avoid counting it as duty hours. On univariate and multivariate analysis there was no significant relationship between gender, age, race, specialty, or level and likelihood of reporting working at home.

Conclusion: Electronic medical records allow the majority of residents to shift some patient care work from the hospital to home. Most residents in our study reported not recording this time as duty hours despite ACGME guidance to the contrary. Our results indicate that residents’ sense of responsibility for their patients continues after they leave the hospital, perhaps mitigating concerns about a “shift-work mentality.” Given the prevalence of work at home, further research should assess its impact on patient care, resident education, and quality of life.

 

40.06 The Impact of a Targeted CDI Intervention on the Documentation Patterns of Surgery Residents

Posted on December 22, 2014

D. Jeffcoach1, T. La Charite1, P. B. Barlow1, C. Powell1, M. Phillips1, M. Goldman1  1University Of Tennessee Medical Center – Knoxville,Surgery,Knoxville, TN, USA

Introduction:
Surgical resident education has become more complex. Challenges include meeting the Next Accreditation System education milestones, the national implementation of the Patient Protection and Affordable Care Act (PPACA), and decreasing resident education funding. In addition, physician reimbursement for surgical procedures has declined over the last decade. To address these concerns we developed a training intervention focused on improving patient documentation. We hypothesize that implementing an individualized targeted clinical documentation intergrety intervention for surgical residents would improve documentation patterns. Success was defined as an increase in geometric mean length of stay, case mix index and reimbursement.

Methods:
With IRB approval a prospective case control study was performed using an individualized targeted intervention. Charts were reviewed for all patients discharged from four surgical services over a one month period. Patient demographics, length of stay (LOS), geometric mean length of stay (GMLOS), case mix index (CMI) and reimbursement was collected. All general surgery residents underwent a personalized thirty-minute intervention reviewing the quality of their documentation using current medical documentation practices. After the intervention a subsequent sample of surgical patients were evaluated using the same endpoints.

Results:
All general surgical residents participated in the study (n = 29). In the pre-intervention group there were 396 patient encounters and 328 in the post-intervention group.  Baseline comparisons were made using Mann-Whitney U and chi-square tests of independence. The proportion of patients representing each service was not statistically different between months. Actual LOS remained constant between groups (4.0, IQR 5.0 vs. 4.00, IQR 5.00; p=0.970). Independent t-tests on primary endpoints found that the disparity between GMLOS and the patient’s actual LOS was narrowed by nearly a full day in the post-intervention month (M = 1.09, SD = 8.17) compared to the pre-intervention month (M = 1.90, SD = 6.69), p=0.134. CMI also increased (CMI=2.25, SD=1.94 vs. CMI=2.47, SD=2.32; p=0.165), as did reimbursement, $11,834 (SD=$12,744) vs. $12,790 (SD=$14,108), p=0.333.

Conclusion:
While reimbursement increased nearly $1,000 per case, GMLOS increased by one day, and the overall CMI increased, statistical significance was confounded by the wide variance amongst surgical patients. These parameters are vital to hospital fiscal solvency and we consider any improvement a success. In addition to improved resident awareness of accurate documentation, we were able to use this data to negotiate increases in resident complement funded by our hospital. This approach is valuable to both prepare residents for successful practice as well as validate their financial benefit to hospital systems as resources for resident education continue to decrease.
 

40.07 Management of Vascular Trauma by Senior Surgical Residents: Perception Does Not Equal Reality.

Posted on December 22, 2014

M. W. Bowyer1, S. A. Shackelford1,2, E. Garofalo1,2, K. Pugh2, C. Mackenzie2  1Uniformed Services University Of The Health Sciences,Norman M. Rich Department Of Surgery,Bethesda, MD, USA 2University Of Maryland,Baltimore, MD, USA

Introduction: Experience with the management of vascular trauma by senior surgical residents is limited. When queried about their understanding of anatomy and ability to perform specific vascular exposures, residents express a moderately high level of confidence. We hypothesized that this perception does not equal reality. 

Methods: 42 senior surgical residents participating in an ongoing validation study of the Advanced Surgical Skills for Exposures in Trauma (ASSET) course were asked to self-assess their baseline (pre-course) confidence of their understanding of the anatomy required to perform, and their ability to perform exposures of the Axillary (AA), Brachial (BA), and Femoral (FA) Arteries, as well as Lower Extremity Fasciotomy (LEF) using a 5 point Likert scale. The residents then performed the 4 procedures on a cadaver model and were scored in real time by pre-trained trauma experts using both a global assessment (5 point Likert scale) of "understanding of anatomy" and "resident is ready to perform", as well an overall numerical score (1-100) of the performance. Statistical analysis was performed using the student t-test with α set at p < 0.05.

Results: As seen in the table, residents consistently rated their understanding of anatomy and their ability to perform the 4 procedures higher than the expert evaluators ultimately scored them.  This was especially pronounced for the lower extremity for both FA exposure and lower extremity fasciotomy. The average global numerical scores for the 4 procedures was between 57 and 66 out of 100 points.

Conclusion: The findings suggest that senior residents are ill-prepared to perform the studied exposures for vascular trauma, and that they have an unwarranted confidence in both their understanding of the anatomy and the ability to perform these procedures. Perception clearly does meet reality in preparing these trainees to perform as advertised, and future curricular offerings and evaluation should address this gap.

 

40.08 Impact of Advanced Practice Providers (NPs and PAs) on Surgical Residents’ Critical Care Experience

Posted on December 22, 2014

S. A. Kahn1, S. Davis1, C. F. Banes1, B. Dennis1, A. K. May1, O. Gunter1  1Vanderbilt University Medical Center,Trauma And Surgical Critical Care,Nashville, TN, USA

Introduction:  Teaching hospitals often employ Advanced Practice Providers (nurse practioners and physician assistants, or APPs) to counteract the restricted work-hours decrease in resident manpower. With the ever growing utilization of APPs in labor intense areas, such as intensive care units (ICUs), APPs are likely to play a significant role in resident education and experience. No studies have been conducted to investigate the direct role an APP plays on the work and training experience of a surgical resident in the ICU. 
 

Methods:  This was an IRB approved survey of surgical residents in the United States. The survey was distributed via email to residents in ACGME-accredited general surgery residencies through their program coordinators. In addition to demographics, residency and ICU characteristics, residents were asked about effects of APPs on various domains of patient care, work flow, and educational experience. Ordinal regression analysis was used to determine predictors of resident perception.
 

Results: 354 of 1178 residents responded to the survey (30%). Of these respondents, 72% were from large-university programs, while 79.3% worked in closed or semi-closed ICUs. APPs worked in 81.6% of ICUs. APPs performed procedures in 73.6% of ICUs, for which residents reported a mild negative effect on their training (score 40/100 [IQR 25.5,55.5] scale:50=neutral, <50=detracts,>50=enhances training). Some residents felt that nurses preferentially calling APPs for patient care issues interfered with education (17%) and residents' ability to follow patients (12%). Most residents reported positive effects of APPs, such as reduced resident work load (79.8%), teaching protocols/guidelines (60.3%), enhanced patient care (60.3%), and enhanced communication (50.5%). When asked how APPs affected their overall ICU experience, 48.4% reported positive effects, 20.6% reported “no effect,” and 31% reported detrimental effects. Nurses calling APPs instead of residents for patient care increased the perception of APPs causing overall detrimental effects to ICU experience (OR 3.7, CI 1.5-9.1), while a view that APPs enhanced the resident-attending relationship was protective against detrimental effects (OR 0.91, CI 0.89-0.93). 

Conclusion: Most residents feel that APPs have a positive or neutral effect on their ICU experience. A minority of residents perceive that APPs detract from training, particularly those who feel excluded when nurses preferentially contact APPs with patient care issues.  APPs have the potential to enhance training and foster a positive ICU experience, as reflected in many of the resident survey responses. Strategies to maintain direct nurse and resident communication might preserve residents' perception of the educational value of APPs.

 

40.09 Using Surgical Bootcamp to Teach Core Entrustable Professional Activities for Entering Residency

Posted on December 22, 2014

V. M. Jones1, E. X. Chen1, J. L. Raque1, E. Sutton1  1University Of Louisville,Department Of Surgery,Louisville, KY, USA

Introduction: Surgical residents are given autonomy early in their training, often with limited direct supervision. The Core Entrustable Professional Activities for Entering Residency (CEPAER, Figure 1) were developed to reduce the gap “between what new residents do without supervision and what they have been documented as competent to do without supervision.” We describe use of a surgical bootcamp to document achievement of CEPAER in medical students entering surgical residency.

Methods: Prior to the course, a focus group about course expectations, including a pre-test of confidence and knowledge about communication and patient care was given. Medical students pursuing surgical residency then completed the 4-week course in the spring of their fourth year. The course featured didactic and hands on instruction in airway management, venous access, surgical technique, obtaining informed consent, radiography interpretation, and obstetric, orthopedic, and plastic surgery emergencies. Educational tools used to teach the course included part task trainers, patient simulators, standardized patients, and direct observation/instruction. Students also participated in the MedEdPortal course “Death on the Wards” and a mock call program administered by two registered nurses. A post course focus group and posttest was conducted. Student achievement of the CEPAER was documented by faculty daily.

Results:We were able to document competency, defined as direct observation of skill without supervision, for all EPAs except numbers 6, 7, and 13, for a total of 10/13 EPAs (77%). Four of nine students were not able to complete the Advanced Cardiac Life Support (ACLS) algorithm (representing EPA 10) for a standardized patient simulation involving myocardial infarction. A two-day refresher course in ACLS was then given in which all students successfully demonstrated competence.

The “Death on the Wards” course significantly increased student confidence and knowledge regarding communication and administrative responsibilities surrounding patient death.  The average assessment of confidence prior to the workshop was 19.78 ± 4.41 (SEM 1.47). After bootcamp, the average was 31.56 ± 4.48 (SEM 1.49) (p < 0.01).  The average assessment of knowledge prior to the workshop was 16.11 ± 3.95 (SEM 1.32). After bootcamp, the average was 31.33 ± 6.12 (SEM 2.04) (p < 0.01).

Conclusion:Surgical bootcamps serve as a framework for documenting achievement and offering remediation of CEPAER.  Further course development can ensure all entrustable professional activities are included in the curriculum.

 

40.10 Evaluation of a Surgery-Based Adjunct Course for Medical Students Entering Surgical Residencies

Posted on December 22, 2014

C. A. Green1, S. M. Wyles1, E. H. Kim1, P. S. O’Sullivan1, H. Chern1  1University Of California – San Francisco,Department Of Surgery,San Francisco, CA, USA

Introduction: Educators have developed preparatory courses for senior medical students (SMS) entering surgery aiming to improve the transition from medical school to residency. We chose to design a novel curriculum that can be embedded in a capstone course to enhance student’s readiness for surgical internship. The course emphasizes major intern competencies, ward management and technical skills, through interactive simulation and practice activities. This study aims to assess the feasibility and outcomes of this course.

Methods: A surgical curriculum was designed and executed based on competencies highlighted in our surgical intern milestones. Students participated in 8 (3-hour) sessions held over four weeks as an adjunct to the well-established intern preparatory course at our institution. Course activities involved interactive simulation cases and mock page encounters to emphasize post-operative patient care and management of the critically ill. Additional sessions included technical skills exercises reinforced with home video assignments. Students rated confidence on 13 management skills using a five-point Likert scale (5=high confidence). Confidence levels were then averaged to give an overall score. Faculty graded students’ technical performance using a global grading scale (1 to 10) for 5 different suturing exercises. Students completed all measures both on the first and last day of the course. Comparisons between pre- and post-course data were made using t-tests (a=0.05).

Results: 11 students entering 4 different types of surgical residencies enrolled in the 2014 course. Assessment of overall confidence in patient management improved from 2.41 to 3.89 (SD 0.49, 0.35; P<0.05). Additionally, student scores on fundamental suturing exercises significantly increased in all 5 tasks (P<0.05) (Figure 1).

Conclusion: We developed and incorporated a surgical component to the existing preparatory course at our institution. Our results illustrate the feasibility of an adjunctive specialty-specific curriculum for SMS entering surgical residencies. Students demonstrated increased confidence in ward management skills and increased technical scores in all measured exercises. The technical improvement is noteworthy because only 3 of the sessions were dedicated to these skills. The significant progress may be due to the additional implementation of the home video component. Investigation into subsequent performance benefits is warranted. This course serves as a specialty-specific model for schools with existing preparatory courses. Our described curriculum allows for consolidation efforts to maximize resources while still highlighting specific components to heighten participants’ readiness for surgical residency.

38.07 National Trends in the Receipt of Post-Mastectomy Radiation Therapy

Posted on December 22, 2014

L. L. Frasier5, S. E. Holden5, T. R. Holden6, J. R. Schumacher5, G. Leverson5, B. M. Anderson8, C. C. Greenberg5, H. B. Neuman5,7  8University Of Wisconsin,Department Of Human Oncology,Madison, WI, USA 5University Of Wisconsin,Wisconsin Surgical Outcomes Research Program, Department Of Surgery,Madison, WI, USA 6University Of Wisconsin,Department Of Medicine,Madison, WI, USA 7University Of Wisconsin,Carbone Cancer Center,Madison, WI, USA

Introduction:  In the past decade, there is new evidence that patients receiving post-mastectomy radiation therapy (PMRT) experience reduced recurrence and an absolute survival benefit, strengthening consideration in patients with risk profiles for which PMRT has not previously been recommended. However, the actual impact of these data on practice has not been examined. We sought to investigate changes in rates of PMRT over time according to risk of recurrence.

Methods:  Female patients with stage I‑III breast cancer who underwent mastectomy from 2000-2011 were identified in the SEER database (n=62,442). Temporal trends in the proportion of patients receiving PMRT were investigated, grouping patients by tumor characteristics associated with prognosis (tumor ≤ vs. > 5 cm; 0, 1‑3, or 4 or more lymph nodes). Joinpoint regression fits a series of joined straight lines together to determine whether there is a statistically significant change in the slope of the line(s) at any given point. We used this to analyze trends of PRMT use over time. Results are further summarized as annual percentage change (APC), or the slope of the line segment. 

Results: The highest receipt of PMRT (initially 62%) was seen in patients at highest risk of recurrence, those with four or more positive lymph nodes (any tumor size) and patients with >5 cm tumors and 1-3 positive lymph nodes. For this group of patients, receipt of PMRT was increasing by 0.8% per year and stable over the study period (no change in slope was identified). PMRT receipt was lowest (initially 7.5%) for patients with tumors ≤5 cm and no positive lymph nodes, and increased by 2.6% per year (no change in slope). In contrast, the cohort of patients with tumors ≤5 cm and 1-3 positive lymph nodes, had a baseline receipt of PMRT of 26.9%, and did not change  from 2000- 2006, after which change of  slope was identified (p=0.0189). Thereafter, the APC increased to 9.0% for the remainder of the study period (2007-2011). 

Conclusion: Since 2000, the use of PMRT has slowly but steadily increased over time for breast cancer patients across risk strata. However, there was a significant acceleration in the increased uptake of PMRT for patients with tumors ≤5 cm and 1-3 positive lymph nodes after 2007, likely representing change in practice patterns related to a broadening of the indications for PMRT in response to new evidence of a survival advantage.  It will be important to monitor the magnitude of benefit from PMRT in current everyday practice to ensure the improvements in disease free survival and overall survival persist and that the benefits of this treatment outweigh the risks.

 

38.08 Adjuvant Chemotherapy in Stage III Colon Cancer Patients Remains Underutilized

Posted on December 22, 2014

A. Z. Becerra1, C. P. Probst1, C. T. Aquina1, B. Hensley1, M. G. Gonzalez1, K. Noyes1, J. R. Monson1, F. J. Flemming1  1University Of Rochester,Surgery,Rochester, NY, USA

 Introduction:
There is strong evidence supporting the efficacy of adjuvant chemotherapy for pathological stage III colon cancer patients. Therefore, understanding factors associated with receipt of chemotherapy is important in order to identify subpopulations that might be at risk of not receiving optimal care. This study explores differences in adherence to evidence-based adjuvant chemotherapy guidelines for pathological stage III colon cancer cases across hospitals and patient subgroups. In addition, the relationship between receipt of chemotherapy and 5-year survival was examined. 

Methods:
Stage III colon cancer patients were identified from the 2003 – 2011 National Cancer Data Base (NCDB). Bivariate analyses assessed factors associated with receipt of adjuvant chemotherapy. Factors achieving a p-value < 0.2 were included in multivariable analyses. Logistic regressions were used to estimate receipt of adjuvant chemotherapy across varying hospital characteristics including geographic location, cancer center type, and hospital volume. Patient factors included were age at diagnosis, year of diagnosis, sex, race/ethnicity, insurance type, household income, education, urban/rural classification, Charlson comorbidity scale, and tumor histology. Kaplan-Meier curves and multivariable Cox proportional hazards models were used to estimate the association between receipt of chemotherapy and 5-year survival for patients diagnosed from 2003-2006. In addition, the population attributable risk of death was calculated to estimate the number of deaths per year that could be avoided had everyone in the sample received adjuvant chemotherapy.

Results:
There were 124,008 patients who met the inclusion criteria. Adjuvant chemotherapy was not administered to 34% of the sample. Of these, 66% did not have a reason as to why chemotherapy was not offered as part of the planned first course of therapy. The rates of adjuvant chemotherapy have shown little improvement over time (63 % in 2003 vs. 66% in 2011). Factors associated with lower odds of receiving adjuvant chemotherapy include no insurance, lower income, worse comorbidity status, and black race. The Kaplan-Meier curves (Figure 1) indicate that patients receiving chemotherapy have better survival (p <0.001). This effect persisted in the multivariable analysis, which estimated a 52% reduction in the hazard of death (HR = 0.48, 95% CI: 0.47-049) in patients who received chemotherapy as compared to those who did not. The population attributable risk is 21% which indicates that over 1,400 deaths per year could be avoided if all stage III patients received adjuvant chemotherapy. 

Conclusion:
There has been no meaningful improvement in receipt of chemotherapy in patients with stage III colon cancer. The fact that chemotherapy was not being considered or offered to over 20% of patients with node positive colon cancer suggests that there are significant process failures across many institutions and regions in the United States.

38.09 Quality of Online Information to Support Shared Decision Making in Breast Cancer Surgery

Posted on December 22, 2014

J. G. Bruce1, J. Tucholka3, H. B. Neuman1,2,3  2University Of Wisconsin,Carbone Cancer Center,Madison, WI, USA 3University Of Wisconsin,Wisconsin Surgical Outcomes Research Program, Department Of Surgery, School Of Medicine And Public Health,Madison, WI, USA 1University Of Wisconsin,School Of Medicine And Public Health,Madison, WI, USA

Introduction:  Decision-making for breast cancer surgery relies heavily on women’s preferences. To reach an informed decision, women require treatment information that is complete, is easily understandable, and encourages them to consider their values in the context of treatment options. Our objective was to assess the quality of online information available to support shared decision making for breast cancer surgery.

Methods:  Four breast cancer surgery-related queries were done on Google and Bing, and websites from the first two pages reviewed. Two investigators evaluated each website for content pertinent to breast cancer surgery using an investigator generated list. The DISCERN instrument was used to evaluate: 1) websites’ structural components that influenced publication reliability, 2) quality of information on treatment choices. Scores on this 16-item validated questionnaire were normalized to a 5-point scale, with scores of 4/5 considered “good”. Agreement between reviewers on overall website quality was assessed.

Results: 45 unique websites were identified and reviewed (kappa 0.80). Websites were general information or health-care portals (48%), .GOV sites (13%), non-profit foundations (18%), hospitals (18%), and Youtube.com (2%). Websites satisfied a median 5/9 (range 0-9) content questions, with 2.2% covering all topics. Commonly omitted topics included: most women being candidates for both breast conservation and mastectomy (67%), the potential for a 2nd surgery to obtain negative margins after breast conservation (60%), post-surgery recovery times (58%), and equivalent survival regardless of surgery (53%). Websites had a median DISCERN score of 2.9 (range 2.0-4.5). Websites achieved higher scores on structural criteria (median 3.57 [2.07-4.71]), with 24.4% rated as “good”. In contrast, scores on treatment choice questions were lower (2.56 [1.3-4.38]), with only 6.7% scoring “good”. Four websites (all non-profit foundations) rated highly on both (figure). However, reviewers perceived these websites to be challenging to navigate, with significant effort required to find key content.

Conclusion: Although numerous online sources of breast cancer information exist, most websites do a poor job providing women with essential information necessary to play active roles in treatment decision-making. Even highly ranked websites provided information in a manner which was difficult to navigate and did not facilitate easy comparison of treatment choices in the context of women’s values. Access to high quality online breast cancer information that is balanced and approachable for Internet users of all experience levels would improve the quality of care provided to breast cancer patients.

 

38.10 Saving Your Tail: How Do We Improve Overall Survival in Anal Cancer?

Posted on December 22, 2014

C. P. Probst1, C. T. Aquina1, A. Z. Becerra1, B. J. Hensley1, K. Noyes1, M. G. Gonzalez1, A. W. Katz2, J. R. Monson1, F. J. Fleming1  1University Of Rochester Medical Center,Surgical Health Outcomes & Research Enterprise,Rochester, NY, USA 2University Of Rochester Medical Center,Department Of Radiation Oncology,Rochester, NY, USA

Introduction:
Since the 1980s, combined modality treatment with radiotherapy (RT) and multi-agent chemotherapy has replaced abdominoperineal resection as the preferred definitive treatment for anal cancer. However, there is little data regarding factors affecting long-term overall survival (OS). This study examined the effect of patient, treatment, and hospital factors as well as year of diagnosis on overall survival.

Methods:
Patients with clinical stage I-III squamous cell carcinoma of the anus with complete information about RT treatment were selected from the 1998-2006 National Cancer Data Base. Bivariate analyses were used to examine differences in 5-year overall survival across patient, treatment, and facility characteristics. Kaplan-Meier curves compared survival differences between patients diagnosed from 1998-2002 and those diagnosed from 2003-2006. Subsequently, factors with a p-value <0.2 were entered into a Cox Proportional Hazards model to examine factors associated with 5-year OS. Factors that did not contribute to model fit were manually removed to produce an optimized final model.

Results:
Of the 11,027 patients that met inclusion criteria, 25% were clinical stage I, 49% clinical stage II and 26% clinical stage III. On Kaplan Meier analysis, minimal improvements in mean overall survival were noted for those diagnosed in later years compared to earlier years. Only 40% of patients were treated with guideline-indicated multi-agent chemotherapy and 45 Gray (Gy) RT dose. Additionally, suboptimal chemotherapy and radiation treatments resulted in reduced survival (Figure 1, p<0.001 for all comparisons). Within the multivariable analysis, numerous factors had a negative impact on OS. Compared to those receiving multi-agent chemotherapy and 45 Gy RT dose, increased hazard of death was observed in those treated with single-agent, no chemotherapy or RT dose less than 45 Gy (HR=1.10 95% CI=1.05-1.16) as well as those with both suboptimal chemotherapy regimen and RT dose (HR=1.35, 95% CI=1.26-1.45). Compared to patients with private insurance, decreased survival was observed among those with no insurance (HR=1.12, 95% CI=1.01-1.24), Medicaid (HR=1.20, 95% CI=1.10-1.30), and Medicare (HR=1.20, 95% CI=1.13-1.26). Compared to white patients, black patients had increased risk of death (HR=1.10 95% CI=1.02-1.19). Male sex was also an independent predictor of poor survival (HR=1.17, 95% CI=1.12-1.23).

Conclusion:
There has been minimal improvement in anal cancer survival over time. Sixty percent of patients are still undertreated, with widespread disparity in survival across patient groups. Utilization of a multi-disciplinary tumor board for anal cancer may help improve the delivery of appropriate treatment to all patients.
 

39.01 The Pitfalls of Recreational Inguinal Herniorraphy

Posted on December 22, 2014

C. T. Aquina1, K. N. Kelly1, C. P. Probst1, J. C. Iannuzzi1, K. Noyes1, F. J. Fleming1, J. R. Monson1  1University Of Rochester,Surgical Health Outcomes & Research Enterprise (S.H.O.R.E.),Rochester, NY, USA

Introduction:  Notwithstanding that inguinal hernia repair is the most common general surgical procedure with an estimated 750,000 repairs performed each year in the United States, there is currently little information regarding the impact of surgeon volume on outcomes following inguinal hernia repair, specifically whether increasing surgeon volume is associated with reoperation rates or resource utilization.

 

Methods:  The New York Statewide Planning and Research Cooperative System database was queried for elective outpatient open inguinal hernia repairs performed in New York States from 2001-2006 using ICD-9 and CPT codes. Low (<25 cases per year) and high (≥25 cases per year) surgeon volume was defined using the bottom tertile and upper two tertiles for number of open inguinal hernia repairs performed per year, respectively.  Bivariate, mixed-effect Cox proportional-hazards, and negative binomial regression analyses were performed assessing for factors associated with reoperation for recurrence, procedure time, and downstream total cost calculated as the sum of total facility charges for initial and recurrent repair.

Results:  Among 129,269 inguinal hernia repairs, the overall rate of reoperation for recurrence within 5 years was 1.7%. The median time to reoperation was 1.8 years where 4.8% of the reoperations were emergent. Recurrent hernia repair was performed by the same surgeon in only 57% of patients. A significant inverse relationship was seen between surgeon volume and reoperation rate, procedure time, and healthcare costs (P<0.001). After controlling for surgeon, facility, operative, and patient characteristics, the difference in procedure time and downstream total cost between low-volume and high-volume surgeons was 23 minutes and $763 per patient, respectively. Of note, facility volume had no effect on reoperation rates or procedure time. If elective inguinal hernia repairs were performed by surgeons with a minimum volume of 25 repairs per year, roughly $5.2 million would be saved each year in New York State alone. Extrapolated across the United States, over $180 million could be saved annually.

Conclusion:  Surgeon volume < 25 cases per year for elective open inguinal hernia repair was independently associated with higher rates of reoperation for recurrence, worse operative efficiency, and substantially higher healthcare costs. Referral to surgeons who perform at least 25 inguinal hernia repairs per year should be considered to decrease reoperation rates and unnecessary resource utilization.
 

39.02 A Screening Program to Prevent Readmission Following Colorectal Surgery

Posted on December 22, 2014

T. R. Grenda1,2, M. R. Hemmila1,2, S. L. Wong1,2, A. Mikhail2, S. E. Regenbogen1,2  1University Of Michigan,Center for Healthcare Outcomes And Policy,Ann Arbor, MI, USA 2University Of Michigan,Department Of Surgery,Ann Arbor, MI, USA

Introduction:  As healthcare reimbursement reform has increasingly penalized hospitals for unplanned readmissions, there is widespread interest in developing interventions to prevent them.  In a high-volume colorectal surgery service, we designed, implemented, and evaluated a pre-discharge screening program aimed at preventing readmission following inpatient colorectal surgery.

 

Methods:  We composed a 10-item screening tool to identify patients at increased risk for postoperative readmission. At discharge, mid-level providers or residents completed the screening and identified patients received a follow-up phone call from clinic nursing staff 48-72 hours after discharge, to identify and redirect patients with problems to early outpatient attention.  We obtained data on comorbidities and outcomes from supplemental review of the electronic medical record. Statistical analysis was performed to compare early (<7 days) and 30-day readmission rates between patients with positive and negative screens, and among those with positive screens, between those who did and did not receive follow-up phone calls.

Results: 290 consecutive patients undergoing colorectal surgery were screened for readmission risk.  193 of these patients (66.5%) screened positive using the tool (Table 1). The 30-day readmission rate was 12.4% for patients screening positive and 3.1% for those screening negative (relative risk 4.0, p=0.009).  The screening tool had a sensitivity of 91% for early readmission and 88% for 30-day readmission.  The positive predictive value of the tool was 5.6% and 12.3% for early and 30-day readmission, respectively.  Of those patients screening positive, only 52% were successfully contacted by nursing staff for follow-up phone call. There were no significant differences in readmission rates, at either 7 days (phone call: 3.9% vs. no phone call: 7.7%, p=0.4) or 30 days (11.8% vs. 13.2%, p=0.8) associated with receiving an intervention phone call. Issues screened for during the phone call did not predict subsequent readmission.

Conclusion: Our study identifies a 10 question tool with high sensitivity for detecting patients at highest risk for readmission after colorectal surgery. However, a targeted early follow up phone call intervention did not appear to prevent readmissions. Future efforts aimed at understanding the specific factors predictive of readmission are needed to guide implementation of effective interventions to prevent postoperative readmissions. 
 

39.03 Use Of Tranexamic Acid In Civilian US Trauma Centers: Results Of A National Survey

Posted on December 22, 2014

R. S. Jawa1, A. Singer2, J. E. McCormack1, C. Huang1, J. A. Vosswinkel1  1Stony Brook University Medical Center,Trauma,Stony Brook, NEW YORK, USA 2Stony Brook University Medical Center,Emergency Medicine,Stony Brook, NY, USA

Introduction:  The antifibrinolytic tranexamic acid (TXA) is listed as essential medication by the World Health Organization, is included in the Joint Theater Trauma System, and is recommended by the Trauma Quality Improvement Program of the American College of Surgeons as part of massive transfusion guidelines. A recent major trauma study further advocated for TXA use.  However, its use in US trauma centers is unknown. We determined surgeon’s familiarity with TXA and use of TXA.  We further hypothesized that military experience would be associated with greater TXA familiarity and use. 

Methods:  An online survey was sent to the 1291 attending surgeon members of a national trauma organization in the spring of 2014. The survey was organized into three parts: respondent demographics, perceptions of TXA, and experience with TXA. Perceptions of TXA use were scored on a 5 point Likert scale.  Chi-squared test was used for statistical analysis and p<0.05 was considered significant.

Results: The survey was completed by 35%.   With regards to demographics, 81.1% had completed a Critical Care fellowship. Military medical experience was reported by 21.0%.  74.5% of respondents work in a Level 1 Trauma Center, and 23% in a Level II trauma center.

With regards to TXA perceptions, a majority of those surveyed agreed or strongly agreed that: TXA reduced bleeding (78.9%), and that a comprehensive massive transfusion protocol should include TXA (82.5%).  Furthermore, 92% of respondents are looking towards national trauma organizations to develop practice guidelines for its use.

Experience with TXA was variable: 38.0% use regularly, 24.9% use it 1-2 times per year, 12.3% use it rarely, and 24.7% have not used it.  Of those who had used TXA, 79.6% indicated that the primary indication is significant hemorrhage; 18.6% felt risk of significant bleeding was an indication.  Amongst respondents who did not routinely use TXA, the primary reason was that they felt that TXA had uncertain clinical benefit (48.3%), followed by unfamiliarity with the drug (32.8%).  TXA unavailability in the hospital was a rare cause (3.6%); 87.2% of respondent's hospitals had TXA on formulary.  While 18.3% of surgeons with military experience had never used TXA, 26.4% of those without military experience had not used TXA, but this failed to reached statistical significance, with p=0.11. 

Conclusion: Currently, only 38% of US trauma surgeons regularly use TXA for significant traumatic hemorrhage.  The major reason for this appears to be unfamiliarity with TXA.  Military experience was not a significant predictor of TXA use in civilian US trauma centers.  The data suggest an opportunity for collaboration amongst members of national organizations to further a guideline for TXA use in significant hemorrhage. 
 

39.04 Surgical Volume, Post-Operative Outcomes, and Overall Patient Satisfaction

Posted on December 22, 2014

S. E. Tevis1, G. D. Kennedy1  1University Of Wisconsin,General Surgery,Madison, WI, USA

Introduction:  Patient satisfaction is an increasing area of interest due to both public reporting of results and tying of Medicare reimbursement to satisfaction scores.  While scores are adjusted for patient factors, little is known about how surgical volume and post-operative outcomes affect satisfaction with the hospital experience. 

Methods:  Hospitals participating in the University HealthSystem Consortium (UHC) database from 2011-2012 were included.  Patients were restricted to those discharged by general surgeons to isolate surgical patients.  Hospital data was paired with HCAHPS results from the Hospital Compare website.  Post-operative outcomes were dichotomized based on the median for all hospitals and stratified based on surgical volume.  Overall patient satisfaction scores, defined as the recommendation of hospital domain, were also dichotomized based on median scores.  Chi square and binary logistic regression analyses were performed to evaluate whether post-operative outcomes or surgical volume more significantly influenced high patient satisfaction.

Results:  The study population consisted of 171 hospitals from the UHC database.   The median surgical volume was 6,341 annual operations.  The median complication rate was 4.15%, median readmission rate was 10.72%, and median mortality rate was 1.24%.  Highly satisfied patients on the recommendation of hospital domain ranged from 46% to 90% with a median of 75%.  High surgical volume was a more important predictor of overall patient satisfaction than post-operative outcomes (Figure 1).  Hospitals with high surgical volume were significantly more likely to have high overall satisfaction scores than low volume hospitals regardless of hospital complication rates (p<0.001).  Similarly, high surgical volume independently predicted satisfaction on the HCAHPS survey regardless of hospital readmission rates (p<0.001) or mortality rates (p=0.009).

Conclusion:  High surgical volume more strongly predicted overall patient satisfaction on the HCAHPS survey than post-operative outcomes.  Patients may find higher volume hospitals more generally impressive and may be less capable of identifying safe, high quality hospitals.

 

39.05 Satisfaction with Surgeon Care as Measured by S-CAHPS is Not Related to NSQIP Outcomes

Posted on December 22, 2014

R. K. Schmocker1, L. Cherney-Stafford1, E. R. Winslow1  1University Of Wisconsin,Surgery,Madison, WI, USA

Introduction: Patient satisfaction is an important component of the patient experience, however measurement of satisfaction with surgical care has been problematic. The recently approved Consumer Assessment of Healthcare Providers and Systems Surgical Care Survey (S-CAHPS) was designed to measure the surgical patient experience. Although previous studies have suggested that satisfaction is not related to postoperative morbidity, this has largely been examined at the hospital level using administrative, measures of morbidity, and more global surveys. We set out to determine, on the patient level, whether the presence of NSQIP complications or other clinical variables impact patient satisfaction on the S-CAHPS.

Methods: All patients undergoing a general surgical operation from 6/13-11/13 were sent the S-CAHPS within 3 days of discharge, with a response rate of 45.3% (456/1007). To assess the impact of malignancy on satisfaction, a subset of operative sites with a high proportion of malignant indications was used (colorectal, thyroid, breast, hepatobiliary). Retrospective chart review was conducted using NSQIP variable definitions. Major complications were defined by the presence of: septic shock, cardiac arrest, stroke, ventilator > 48hrs, unplanned intubation, or organ space infection. Data were analyzed as a function of response to the overall surgeon-rating item, and those surgeons rated as the “best possible” or topbox were compared with those lower ratings using χ2 and t-tests as appropriate.

Results:253 patients were identified, 68% female, with an age of 59±16 yrs, BMI of 28.2±7 kg/m2, and length of stay (LOS) 4.5±6.7 days. 79% of respondents rated the surgeon as topbox. Age, BMI, ASA class, and LOS were similar between those who rated the surgeon as topbox and those that did not. The overall NSQIP complication rate was 20% (48/243) with 23% of those (11/48) being major complications. Neither the complication rate (total or major) nor the number of complications impacted satisfaction scores (Table). Similarly, a malignant indication for the operation, having an urgent operation, or being discharged to somewhere other than home were not associated with satisfaction scores.

Conclusion:Even when examined on a patient-level with surgery-specific measures and outcomes, the presence of complications after an operation does not appear to impact overall patient satisfaction with surgeon care. This, in conjunction with the finding that satisfaction does not appear to be impacted by other important clinical variables such as malignancy, suggests that satisfaction may be an outcome distinct from traditional measures. Further investigation into the primary determinants of this unique outcome is needed.

 

39.06 Influence of Body-Mass Index on Outcomes Following Major Resection for Cancer

Posted on December 22, 2014

C. K. Zogg1, B. Mungo2, A. O. Lidor3, M. Stem3, K. S. Yemul1, A. H. Haider1, D. Molena2  1Johns Hopkins University School Of Medicine,Center For Surgical Trials And Outcomes Research, Department Of Surgery,Baltimore, MD, USA 2Johns Hopkins University School Of Medicine,Division Of Thoracic Surgery, Department Of Surgery,Baltimore, MD, USA 3Johns Hopkins University School Of Medicine,Department Of Surgery,Baltimore, MD, USA

Introduction:  More than 1 in 3 adults in the United States, accounting for >106 million people, is obese. From a surgical perspective, the high prevalence of obesity means that operations on this population are common in everyday practice. Despite the assumption that obesity is associated with increased surgical risks, current evidence to suggest that obese patients fair worse is inconclusive. This study sought to examine associations between body-mass index (BMI) and outcomes following major resection for cancer using a nationally-validated outcomes-based database.

Methods:  Data from the 2006-2012 American College of Surgeons NSQIP were queried for patients ≥18 years of age with a primary ICD-9 cancer diagnosis and corresponding CPT code for lung surgery, esophagectomy, hepatectomy, gastrectomy, colectomy or pancreatectomy. BMI calculated for included patients were categorized according to World Health Organization classification (Table). Patients were compared first via single logistic regression for differences in 30-day mortality, extended length of stay (LOS), serious morbidity, overall morbidity and isolated morbid conditions among three cohorts: normal vs. (1) underweight, (2) overweight-obese I and (3) obese II-III. Similar methodology was employed using multivariate logistic regression adjusted for clinical/demographic factors and type of resection preformed. Risk-adjusted, stratified analyses for each resection were also considered in addition to an overall propensity score-adjusted logistic analysis (Table).

Results: Consistent with the distribution of BMI in the United States, we identified 529,955 patients of whom 32.06% (169,880) were normal weight, 3.45% (18,284) underweight, 32.52% (172,355) overweight and 17.76% (93,669), 7.51% (39,820) and 4.94% (26,177) obese I-III. Unadjusted, multivariate and propensity-score adjusted logistic regression found that 30-day mortality, extended LOS and serious and overall morbidity were significantly increased in cohort 1. Overall, we did not observe worse surgical outcomes in cohort 2; although, these patients had increased risk for isolated complications such as wound infection, venous thromboembolism, prolonged mechanical ventilation and renal complications. In cohort 3, obese patients experienced a 3-9% increased odds of overall and serious morbidity. Analyses stratified by cancer-resection type reported similar trends.

Conclusion: Evidence-based assessment of outcomes following major resection for cancer suggests that obese patients should be treated according to optimal oncologic standards Surgeons should not be hindered by unproven perceptions of prohibitively increased perioperative risk in this population.

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