98.20 Does Gender Affect Online Reviews: An Analysis of Physician Ratings Assessing for Gender Differences

Posted on January 31, 2019

K. Marrero1, E. King1, A. Fingeret2  1St. George’s University School Of Medicine,St. George’s, St. George’s, Grenada 2University Of Nebraska College Of Medicine,Omaha, NE, USA

The increasing use of review websites by consumers has become a crucial first step in choosing a physician with more than half of Americans consulting review sites prior to physician selection. While prior research has analyzed online reviews of physicians, a difference in these surgeon reviews based on gender of surgeon has yet to be assessed. We sought to identify whether differences exist in the quality and content of online reviews for men versus women surgeons.

Using a deliberate sampling algorithm of the two most populated physician review websites, RateMDs.com and Yelp.com, we purposefully sampled reviews for the top 20 surgeons per tercile of search results for general and subspecialty surgeons from the four most populated urban areas in the United States: New York, Houston, Los Angeles, and Chicago. A qualitative assessment was performed using grounded theory content analysis of major and minor thematic elements including: global rating – overall experience, would return to provider, hostility, would recommend to others; communication – professional, welcoming, accommodating, honest, made comfortable, bedside manner; technical – outcomes, attention to detail, healing process, informative, technical skill, safety; and comments on ancillary elements – staff interactions, wait time, insurance issues, litigation, and scheduling. Plastic and reconstructive surgeons were excluded to eliminate reviews by aesthetic surgery patients.

 

Four-hundred and thirty-nine online patient reviews were identified for 231 surgeons from RateMDs.com (51%) and Yelp.com (49%). Seventy-six percent of reviews were of male surgeons, mimicking the gender difference in the actual workforce.

Most themes mentioned in online reviews were positive with male surgeons having an average of 75 percent positive reviews while female surgeons had an average of 68 percent positive reviews.

The content of online physician reviews differed for men and women surgeons. Women surgeons were more likely to have comments on social interactions and bedside manner, while men surgeons were more likely to have a global review or mention of technical skill (Table 1).

 

While online reviews of surgeon include both male and female counterparts, the content of reviews differs by gender. While men surgeons have more comments on the overall experience and technical aspects, women surgeons are critiqued more on their social skills.

 

98.19 Perioperative Outcomes of Varying Esophagectomy Approaches in the Treatment of Esophageal Malignancy

Posted on January 31, 2019

E. N. Konrade1, R. Morse1, T. Mouw2, M. Moreno1, P. DiPasco2, M. Al-kasspooles2  1University of Kansas,School Of Medicine,Kansas City, KS, USA 2University of Kansas Medical Center,Department Of Surgery,Kansas City, KS, USA

Introduction: Although the disparity between various esophagectomy approaches have previously been described, there is a paucity of data describing perioperative outcomes and morbidity with the changing demographics of esophageal cancer. As adenocarcinoma surpasses squamous cell carcinoma as the dominant pathologic subtype, a concern has been raised that older studies are no longer applicable.

Methods: Using the University of Kansas Medical Center (KUMC) database (2007 to 2018),  we identified 245 patients who underwent esophagectomy for esophageal cancer. Patients were then stratified into three groups based on the esophagectomy approach and included: Ivor-Lewis (transthoracic), transhiatal esophagectomy (THE) and minimally invasive esophagectomy (MIE). We evaluated operative mortality, length of stay and morbidity for each approach. As a surrogate for postoperative quality of life, we also assessed the subsequent need for anastomotic dilation and stenting.

Results: 53 patients underwent the Ivor-Lewis approach (22%), 62 patients underwent the minimally invasive approach (25%), and 130 patients underwent the THE approach (53%). 81% percent of the patients were male, with an average age of 62.5 years and average BMI of 28.2. 78% of patients had adenocarcinoma with 73% having neoadjuvant chemoradiation. Median operative time was 336 minutes. 5.7% of Ivor-Lewis patients developed an anastomotic leak, while 9.4% and 15.9% leak rates were observed in the MIE and THE groups, respectively. Stenosis developed in 5.3% of Ivor-Lewis, 6.9% of MIE and 12.7% of THE patients. If a leak was present, stenosis occurred in 2.9% of Ivor-Lewis, 4.9% of MIE and 11% of THE patients. Median comprehensive complication index scores were 26.2, 31.4 and 25.7 for Ivor-Lewis, MIE, and THE, respectively. The average length of stay was 20 days for MIE, 15 days for THE and 14 days for Ivor-Lewis. The readmission rate was 35% with average time to readmit 37.7 days, 20.7 days, and 27.5 days for Ivor-Lewis, MIE and THE respectively.

Conclusion: MIE was associated with a longer length of hospital stay and increased perioperative complications as compared to Ivor-Lewis or transhiatal approaches. Time to readmission was also shorter with MIE.
 

98.18 Risk Factors for Pulmonary Artery Embolization (PE) following Deep Venous Thrombosis (DVT)

Posted on January 31, 2019

N. J. Gargiulo1, L. Flores1, A. J. Tortolani1, P. Haser1, G. AlAwawa1, M. Amman1, M. Leiva1, M. Khalil1, C. LaPunzina1, F. J. Veith1  1The Brookdale University Hospital & Medical Center,Vascular,New York, NEW YORK, USA

Introduction:   The prevention of deep venous thrombosis (DVT) and pulmonary artery embolization (PE) continues to remain a vexing clinical challenge not only for inpatients but also in outpatients.  Numerous recommendations have been advocated for DVT/PE prophylaxis and yet there still remains a national reported incidence of 0.5% to 1.9%.  Several risk factor scales have been employed to predict the development of DVT.  It remains unclear, however, which DVTs progress to pulmonary artery embolization (PE).  The purpose of this study was to elucidate which risk factors, if any, may result in venous thrombotic embolization to the pulmonary arteries (PE).

Methods:   A prospective hospital-wide quality study was initiated over an 8 month period evaluating all inpatients and outpatients presenting with acute DVT.   All DVTs were diagnosed by duplex ultrasound performed by certified vascular technologists.  The real time images were interpreted by 2 certified vascular surgeons.  An acute DVT was diagnosed by thrombus echogenicity, change in vein diameter, diminished compressibility and lack of respiratory phasicity.  All PEs were diagnosed by pulmonary artery computed tomographic arteriography (PACTA).

Results:  A total of 234 patients were identified with acute DVT (190 (81%) patients with DVT alone and 44 (19%)  patients with DVT and PE).  The two cohorts were similar with regards to age, gender, site of venous thrombosis, hypercoagulable profile, oncologic manifestations, neurosurgical and orthopedic injuries, and other associated traumatic (i.e. abdominal, chest, vascular) injuries.  Those patients with DVT and concomitant PE had a statistically higher incidence of catheter directed thrombolysis and inferior vena cava filter placement (p<0.05).  There were no identifiable risk factors in the DVT/PE cohort that could have predicted the observed pulmonary artery embolization (PE). 

Conclusion:  In this prospective study, there are no identifiable risk factors for patients with DVT and concomitant PE to explain the observed pulmonary artery embolization (PE).  This may support the concept that DVT and PE are in fact intrinsic venous thromboses unrelated to embolic physiology.    

 

98.17 Parental Decision Making on Newborn Circumcision: What Knowledge Makes the Cut?

Posted on January 31, 2019

A. M. Morgan1, Y. Hu1,2, G. M. Lockwood3  1Feinberg School Of Medicine – Northwestern University,Chicago, IL, USA 2Ann & Robert H. Lurie Children’s Hospital of Chicago,Chicago, IL, USA 3University Of Iowa,Iowa City, IA, USA

Introduction: Newborn circumcision is the most common surgical procedure performed in the United States. Like any surgery, circumcision has inherent medical benefits and risks, with some adverse events requiring reoperation. Professional medical organizations stress that access to circumcision in newborn males and third-party payer coverage is justified, but the ultimate decision of whether to circumcise should be left to parental discretion. There is a paucity of data regarding how parents gather and process information in order to make this decision.  

Methods:  Between March and June of 2017, semi-structured open-ended interviews were conducted with mothers of newborn males during their postpartum hospitalization. Purposeful sampling with a random component was employed to ensure inclusion of subjects of differing races, ethnicities, and religions, as well as decisions to circumcise. Interviews were audio recorded and transcribed. Each transcript was coded by multiple independent reviewers, using a grounded theory approach to identify emergent themes regarding attitudes towards, sources of information about, and decision-making surrounding circumcision.

Results: Ten mothers were interviewed, of whom six planned to circumcise and four did not. Major themes emerged with regards to the decision to circumcise: the importance of cultural norms, limited yet influential discussions, and the lack of, but desire for, more knowledge (Table). Mothers’ decisions were strongly influenced by cultural and familial norms. Many parents had only very limited discussions, if any, about the decision and procedure with one another and with medical providers. Parents who had thorough conversations with their physicians found provider input to be highly influential. Parents’ baseline knowledge of the risks and benefits of the procedure was limited and not evidence-based. They uniformly desire more information and counseling from their medical providers.

Conclusion: In this cohort, parental decision to circumcise was primarily driven by social and cultural influences, particularly father’s circumcision status. Parents often lack empiric knowledge about the procedure, and conversations with medical providers are very limited. Provider knowledge and willingness to discuss the risks and benefits of circumcision with parents is vital to improving shared decision-making and empowering parents to make informed circumcision decisions consistent with their own values. Decision aids with current and evidence-based information regarding circumcision may help both parents and providers to openly discuss this controversial topic and fill a critical information gap.

98.16 Perceptions of Quality in Health Care at the Volta River Authority Hospital, Ghana

Posted on January 31, 2019

M. G. Katz1, C. Spangler1, T. Valmont3, C. Arhinful3, S. Manortey2, S. Talboys2, R. Price1, S. Finlayson1, B. Smith1, M. McCrum1  1University Of Utah,Department Of Surgery,Salt Lake City, UT, USA 2Ensign College of Public Health,Kpong, EASTERN REGION, Ghana 3Volta River Authority Hospital,Department Of Surgery,Akosombo, EASTERN REGION, Ghana

Introduction:

Quality improvement is an essential component of surgical capacity building in low-and middle-income countries.  As quality of care may be viewed differently in this environment, developing a shared understanding of this concept and priorities for intervention is key to designing appropriate interventions and building global partnerships.  The Volta River Authority Hospital in Ghana holds a regional reputation for high-quality care.  We sought to understand provider perspectives of health care quality in this resource-limited setting.

Methods:

Semi-structured interviews were conducted with physicians, nurses and staff at the VRAH to explore perceptions of the meaning and importance of quality in health care.  Interviews were transcribed and qualitatively analyzed using emergent theme analysis.

Results:

Fourteen staff members weresurveyed. Patient-centeredness was a common theme, with most participants describing patient satisfaction as an essential element of quality care. While basic resources were mentioned as a challenge by most subjects, all agreed that resource limitations should not be a barrier to pursuing continuous quality improvement. Subjects stressed the importance of outcome measurement to support quality improvement, but acknowledgedthat a robust mechanism to do so is currently lacking. 

Conclusion:

Qualitative evaluation of perceptions of health care quality at VRAH reveal a focus on exceptional patient experience despite concerns specific to a low-resource setting.  All staff felt that delivering high-quality care is feasible in a resource-limited environment, and that outcome measurement should be prioritized.  These findings will inform efforts to design effective quality improvement initiatives at VRAH. Future work is needed to determine if these perceptions of quality are common across low-resource settings.

98.15 Pathology-Specific Complication Rates, Morbidity and Mortality in Patients Undergoing CRS-HIPEC

Posted on January 31, 2019

M. L. Moreno1, E. Konrade1, T. Mouw2, M. Woody-Fowler1, C. Coker1, M. Jones1, M. Al-Kasspooles2  1University of Kansas,School Of Medicine,Kansas City, KS, USA 2University of Kansas Medical Center,Department Of Surgery,Kansas City, KS, USA

Introduction: While literature exists regarding the operative and clinical outcomes of CRS-HIPEC according to pathology, sample sizes remain low in most studies. The pathologic-specific outcomes have yet to be established in a large sample size.

Methods: A total of 230 patients who underwent cytoreductive surgery (CRS) plus hyperthermic intraperitoneal chemotherapy (HIPEC) at the University of Kansas Medical Center (KUMC) were analyzed and sub-divided into five groups according to their primary tumor pathology. Morbidity, mortality, clinical outcomes, and perioperative outcomes were reviewed among the pathology specific subgroups. ANOVA and chi-squared statistical analysis were performed between groups to assess for statistical significance.

Results: The most common primary diagnosis was colonic adenocarcinoma (59.6%) followed by gynecologic primary (15.2%), other/unspecified (12.6%), appendiceal low-grade mucinous neoplasm (7.4%) and primary peritoneal (3.5%). The average length of hospital stay was 12.7 days in the primary gynecologic group, 11.4 days for other/unspecified, 10.4 days for colonic adenocarcinoma, 9.1 days for primary peritoneal and 8.1 for appendiceal low-grade mucinous neoplasm. Readmission rate was highest in other/unspecified (37.9%) and lowest in the low-grade appendiceal neoplasm group (17.6%) (p-value=0.68). Average comprehensive complication index (CCI) scores were highest in the primary gynecologic group (34) and lowest in the primary peritoneal (20.6) (p-value=0.19). However, the average CCI score for gynecologic malignancy was higher when compared to colonic adenocarcinoma, (p-value=0.01).

Conclusion: HIPEC is associated with longer length of stay and CCI scores in patients with a primary gynecologic diagnosis. No association was observed for readmission rates between subgroups.

 

98.14 Smoking and GI cancer patients—is smoking cessation an attainable goal?

Posted on January 31, 2019

J. R. Barrett1, L. Cherney-Stafford1, E. Alagoz1, M. Piper2, J. Cook2, S. Campbell-Flohr2, S. M. Weber1, E. R. Winslow1, S. M. Ronnkleiv-Kelly1, D. E. Abbott1  1University Of Wisconsin,Surgical Oncology,Madison, WI, USA 2University Of Wisconsin,School Of Medicine And Public Health, Center For Tobacco Research An Intervention,Madison, WI, USA

Introduction:

The negative consequences of tobacco use during cancer treatment are well-documented, but there are no high quality, patient-level data to help us understand patient beliefs about continued smoking (versus cessation) during gastrointestinal (GI) cancer treatment. We aimed to better describe patient attitudes about smoking cessation during cancer treatment.

Methods:

We conducted semi-structured interviews with 10 patients who were active smokers being treated for GI cancers; we also interviewed 5 caregivers. All interviews were audio-recorded, transcribed verbatim, and uploaded to NVivo for data management and analysis. We consensus coded 10% of data inductively using conventional content analysis and developed our codebook and code descriptions. We collaboratively developed data matrices to categorize the themes regarding patient perspectives on smoking as well as presumed barriers to smoking cessation during active therapy.

Results:

Our interviews revealed three consistent themes. First, smoking cessation is not necessarily desired by many patients who have received their cancer diagnosis. Second, failure in past attempts may lead to patients feeling hopeless about future attempts, especially at such a stressful time. Third, while all patients were heavy smokers and received smoking cessation treatment throughout their life, there was little to no perceived smoking cessation treatment at the time of their cancer diagnosis.

Conclusion:

Because GI cancer patients who smoke perceive a lack of dedicated smoking cessation treatment (both counseling and pharmacologic therapy), well-designed coaching sessions educating patients—as well as providers— may be helpful in promoting healthy tobacco-free behavior during cancer treatment. However, these data also suggest that this patient population exhibits feelings of hopelessness and/or a lack of desire to quit tobacco. These realities must be considered as leaders consider dedicating valuable human and fiscal resources to smoking cessation in this population.

98.13 Patient Perspectives on Weight Management for Living Kidney Donation

Posted on January 31, 2019

M. N. Mustian1, M. Hanaway1, V. Kumar1, B. A. Shelton1, P. A. MacLennan1, R. D. Reed1, R. Grant1, B. Terry1, J. E. Locke1  1University Of Alabama at Birmingham,Surgery/Transplantation,Birmingham, Alabama, USA

Introduction: Living kidney donors (LKDs) with obesity have increased perioperative risks and elevated risk of end-stage renal disease post-donation. Consequently, obesity serves as a barrier to living kidney donation, and although there is no general consensus in the transplant community regarding selection of obese LKDs, many transplant centers encourage or require weight loss prior to donation for potential LKDs with obesity. Therefore, this study sought to assess patients’ perspectives on weight management strategies prior to donation among obese LKD candidates, and we hypothesized that willingness to participate in a weight loss program may be associated with donor-recipient relationship. 

Methods: Obese (BMI ≥ 30 kg/m2) LKD candidates evaluated at a single institution from 9/2017-8/2018 were recruited. A survey was administered, including questions regarding LKD candidates’ baseline exercise and dietary habits, as well as interest in weight management strategies for the purpose of kidney donation approval. Participants were then grouped by relationship to the recipient (first-degree relative or spouse (n=25), compared with all other relationships(n=19)). Descriptive statistics were employed to summarize the survey data, and bivariate analyses were performed.

Results:44 of 45 obese LKD candidates who were approached completed the survey. The majority of participants were female (59.1%), white (63.6%), and the mean participant age was 39.0 years. Nearly 90% of participants expressed willingness to lose weight if necessary to become eligible for donor nephrectomy. 84.1% of participants expressed an understanding of the association between obesity and risk of developing kidney disease, and 97.7% of respondents were interested in weight loss pre-donation to decrease that risk. Additionally, 84.1% of participants communicated an interest in a combined diet and exercise program for pre-donation weight loss. Compared with all other LKD candidates, first-degree relatives and spouses of potential recipients were more likely to be interested in exercise programs (p=0.046) and combined diet and exercise programs (p=0.01) at our institution (Figure). Only 29.6% were interested in bariatric surgery.

Conclusion: Among obese LKD candidates, there was an interest in weight loss for the purposes of living kidney donation approval particularly among first degree relatives and spouses of potential recipients. Future programs designed to promote weight management efforts for obese LKD candidates should be considered.

98.12 The Increasing Incidence of Stroke in Trauma Patients: Is it BCVI or age related?

Posted on January 31, 2019

C. Slovacek2, H. Indupuru1,2, E. Fox1,2, S. Savitz1,2, M. McNutt1,2  1Memorial Hermann Hospital,Red Duke Trauma Institute,Houston, TX, USA 2McGovern Medical School at UTHealth,Houston, TX, USA

Introduction: While evidence based medicine guides early diagnosis and treatment of blunt cerebrovascular injury (BCVI) to decrease stroke rates, there is a paucity of trauma research addressing other etiologies of stroke including atherosclerotic disease and atrial fibrillation.  Both are age-related diseases that should contribute to a rising stroke rate with the increasing age of the trauma population.  The purpose of this study is to evaluate the incidence, treatment, and etiology of strokes in our trauma population, and for those related to BCVI to evaluate the impact that screening and treatment guidelines have on the incidence of BCVI-related strokes. 

Methods: This study was a retrospective review of all adult trauma patients admitted to a level 1 hospital who suffered a stroke during trauma admission from 2010 to 2017.  Data was collected from two prospectively maintained databases by the UTHealth Trauma and Stroke services.  Chi-squared test was performed for trends in proportions.  Mann-Whitney U test was used to compare continuous variables.

Results:Of the 43,674 adult blunt trauma patients admitted during the study period, 97 (0.2%) were diagnosed with a stroke during the index admission, of which 22% were caused by BCVI.  The age and volume of trauma patients increased during the study period as did the incidence of BCVI (p<0.001). While the incidence of all strokes increased over time (p<0.001), this was associated with a decrease in BCVI strokes and an increase in non-BCVI strokes.  Of our patients with BCVI-related strokes, 79% received appropriate anti-thrombotic therapy at a median of 6 hours and 59 minutes from time of arrival.  Patients with non-BCVI strokes (78% of the stroke population) had a higher median age (71 vs 44, p<0.001), lower median ISS (12 vs 26, p<0.001) and similar length of stay (12 vs 14 days, p=0.986) compared to patients with stroke secondary to BCVI.  The mortality rate for BCVI strokes and non-BCVI strokes were 38% and 22% respectively, and patients with BCVI strokes were 1.7 times more likely to die than non-BCVI strokes (RR: 1.70, 95%CI: 0.86-3.39, p=0.14).

Conclusion: Strokes are rare in the trauma population but are increasing as the trauma population ages.  Despite a large volume of evidence for BCVI treatment and stroke prevention, the majority of strokes are secondary to advanced age and comorbidities.  Medical optimization of comorbid conditions during trauma hospitalization will become increasingly important for stroke prevention as the population ages. 

 

98.10 Surveying Caregivers of NICU Infants after Transitioning Home

Posted on January 31, 2019

B. Tang1,2, J. K. Chica1,2, N. B. Hebballi1,2, M. A. Bartz-Kurycki1,2, E. I. Garcia1,2, K. C. Kelly3, C. U. Aneji3,5, E. A. Hillman3,5, C. G. Kerl1,2, K. Tsao1,2, M. T. Austin1,2  1McGovern Medical School at UTHealth,Department Of Pediatric Surgery,Houston, TX, USA 2Children’s Memorial Hermann Hospital,Department Of Pediatric Surgery,Houston, TX, USA 3Children’s Memorial Hermann Hospital,Division Of Neonatology,Houston, TX, USA 4Cizik School of Nursing at UTHealth,Houston, TX, USA 5McGovern Medical School at UTHealth,Department Of Pediatrics,Houston, TX, USA

Introduction: The transition from the neonatal intensive care unit (NICU) to home can be a period of high parental stress, which may lead to a negative impact on the healthcare outcome of the infant. There are many factors that influence this discharge process, as well as the immediate period at home after discharge. Our aim was to evaluate potential barriers to a successful discharge and identify opportunities to improve the transition to home by surveying parents of recent NICU graduates.

 

Methods:  A cross-sectional survey was developed in English and Spanish and included the following categories: pregnancy course, pre-discharge education, post-discharge needs, and general demographics. The survey was revised based on stakeholder feedback and then administered to parents of infants discharged from our NICU between January 1, 2018 and July 30, 2018.  The surveys were conducted in our institution’s high-risk infant and pediatric surgery clinics.

Results: A total of 45 parents of recent NICU graduates were surveyed. Of the 45 survey responses, 37 were in English and 8 in Spanish. About 1/2 of the infants were discharged with durable medical equipment (DMEs). The most common DMEs were feeding tubes and supplementary oxygen. Of the families discharged with DMEs, all reported that they felt comfortable with the instructions given prior to discharge. However, after discharge, 25% reported it took longer than one week to feel comfortable using their DMEs. About 1/3 of all parents reported never referring to the discharge paperwork provided to them by the NICU. Of the 10 respondents who referred to the discharge paperwork daily, 6 completed the survey in Spanish. When asking about the use of technology, 75% of families reported that they own either a smartphone or a tablet. Of these, about ½ already use their smartphone in the care of their child, and 3/4 strongly agree or agree that they would utilize a telehealth application to help with the care of their child.

Conclusion: Although most parents of NICU graduates reported feeling comfortable with the discharge process, they often did not feel comfortable in caring for their infants at home.  In addition, a large percentage of families do not refer to discharge paperwork for information following discharge.   However, many already use mobile health tools to help care for their child and the majority are in favor of a telehealth application specifically designed to support parents in caring for NICU graduates. 

 

98.09 Barriers Faced by Parents of Infants Transitioning Home from the NICU: Analysis of a Group Interview

Posted on January 31, 2019

C. G. Kerl1,2, J. K. Chica1,2, M. A. Bartz-Kurycki1,2, M. J. Ottosen4, E. I. Garcia1,2, N. B. Hebballi1,2, K. C. Kelly3, K. Tsao1,2, C. U. Aneji3,5, E. A. Hillman3,5, B. Tang1,2, M. T. Austin1,2  1McGovern Medical School at UTHealth,Department Of Pediatric Surgery,Houston, TX, USA 2Children’s Memorial Hermann Hospital,Department Of Pediatric Surgery,Houston, TX, USA 3Children’s Memorial Hermann Hospital,Division Of Neonatology,Houston, TX, USA 4Cizik School of Nursing at UTHealth,Houston, TX, USA 5McGovern Medical School at UTHealth,Department Of Pediatrics,Houston, TX, USA

Introduction:  Transitioning from the Neonatal Intensive Care Unit (NICU) to home is a vulnerable time for parents of NICU infants. This transition to home is the period in which parental knowledge, skills, and resources can have tremendous impact on the infant’s outcome. Uncertainty exists as to the barriers parents experience when transitioning home from the NICU. We conducted a group interview with parents of former NICU infants to understand challenges faced by parents during the discharge process when transitioning home.

 

Methods:  A group interview was conducted November, 2017 with ten parents of former NICU infants recruited from the NICU Parent Advisory Council and by recommendations of NICU social workers/discharge coordinators. The group interview was conducted by a qualitative researcher, audio recorded and transcribed. A thematic content analysis of the coded data was performed by the research team. A base of 40 codes was created inductively and deductively by the research team to answer the research question.  Codes were assigned to quotations in the transcript by members of the research team and then discussed as a group to reach consensus of the emergent themes.

 

Results: This group of parents identified multiple challenges in the discharge process. Major themes included lack of support, information sharing, lack of preparedness or parental education on durable medical equipment, expectations, and feelings of anxiety / overwhelming stress (see Table). Parents often lacked a robust support system on an emotional, mental, and physical level. Anxiety and stress surrounding the unknown and the information gap that existed with respect to the complex care of their child were commonly described by parents. Some parents also felt unprepared with regard to operating various forms of durable medical equipment. They stated that information regarding discharge schedule and care management changes were not always clearly communicated. Parents highlighted the use of social media to seek further information to address these barriers. To help manage the complex care of their children, parents developed their own schedules, checklists, and alarms.

 

Conclusion: This study identified specific barriers that parents of our NICU infants have when transitioning home. As such, this raises the need to create a program that may address these barriers in order to improve not only patient satisfaction, but also improve healthcare outcomes in our most vulnerable population. 

98.08 An analysis of surgical literature trends over four decades

Posted on January 31, 2019

T. D. Madni1, P. Nakonezny1, H. G. Mayo1, J. B. Imran1, L. Taveras1, R. Vela1, Y. Goldenmerry1, A. T. Clark1, H. B. Cunningham1, M. W. Cripps1, H. A. Phelan1, S. E. Wolf2  1University of Texas Southwestern,Surgery,Dallas, TEXAS, USA 2University of Texas Medical Branch at Galveston,Surgery,Galveston, TEXAS, USA

Introduction:
Topics in surgical literature have evolved over time. We reviewed four decades of surgical publications to determine changes in focus in surgical science.

Methods:
We searched Ovid MEDLINE on 12/5/17 for articles published in Annals of Surgery, JAMA Surgery, Surgery, Journal of the American College of Surgeons, and American Journal of Surgery during years: 1984-86, 94-96, 04-06, 14-16; articles indexed to editorial, letter, or news were excluded. Three surgeons independently assigned two classifications to each article: 1) 1 of 22 subspecialty categories, 2) basic/translational science (yes/no). Intra-class Correlation Coefficients (ICC) assessed rater reliability.   

Results:
N=16225 articles were identified (1984-86: 3881, ‘94-96: 3415, ‘04-06: 3861, ‘14-16: 5068). Surgical literature increased on average 132 publications/year. ICC for raters of subspecialty categories was 0.833 (95% CI:  0.828 to 0.837;p=.0001), and ICC of basic science assignment was 0.870 (95% CI: 0.866 to 0.873;p=.0001). Overall, basic science publications decreased from 16 to 4% (-4.0% of the literature/decade). Significant decreases were noted in general/acute care (-2.8% of the literature/decade) and vascular surgery (-4.1% of the literature/decade).  Significant increases were seen in surgical oncology (+2.7 of the literature/decade) and other, which included outcome and education topics (+4.2% of the literature/decade) (Fig 1). Post-hoc analysis of other demonstrated increased surgical education publications from 0 to 6% between 1984-86 to 2014-16.

Conclusion:
This study reflects trends in surgical literature, demonstrating increased focus on both cancer and surgical education. We found a drastic decline in basic science and vascular surgery investigations, reflecting a significant shift from these fields in the common surgical literature.
 

98.07 Stakeholder’s Perception of Barriers to a Successful Transition to Home of NICU Graduates

Posted on January 31, 2019

N. B. Hebballi1, M. A. Bartz-Kurycki1, K. C. Kelly1, E. I. Garcia1, J. K. Chica1, K. Tsao1, C. Aneji1, E. A. Hillman1, M. T. Austin1  1McGovern Medical School at UTHealth and Children’s Memorial Hermann Hospital,Department Of Pediatric Surgery,Houston, TX, USA

Introduction: Neonatal Intensive Care Unit (NICU) graduates often represent children with complex medical needs. Previously, we found that 22% of NICU graduates had at least one unplanned healthcare visit within 90 days of discharge, including emergency department visit, unplanned clinic visit and hospital readmissions. Given this high rate of unplanned healthcare utilization, we aimed to identify barriers to a successful transition from the NICU to home.

Methods: We conducted semi-structured interviews with 21 participants including 8 parents, 4 physicians, 7 nurses and 2 discharge coordinators to investigate their perceived barriers to a successful transition to home. We used Ishikawa (fishbone) diagram with fish’s head as the problem (infant’s readmission) and backbone of the fish listing out all barriers that contributed to the problem. Ishikawa diagram is a visualization tool used for categorizing the possible causes of a problem in order to identify its root causes. Potential barriers were categorized into policy, process, electronic health record (EHR)/hospital environment, information/material, healthcare providers and parents/families.

Results: A total of 32 barriers were identified across all the categories combined. The most barriers fell into the healthcare providers category (28%) followed by process (22%). Healthcare providers specified the following barriers: lack of a discharge checklist; lack of standardized discharge process and hand off process between NICU nurse and home health nurses; communication gap between physicians, NICU staff and parents; timing of discharge orders placements in the EHR; providers with varied level of experience; disconnect between inpatient and outpatient EHR systems and complex discharge related paperwork. Parents listed lack of DME training and comprehension at the hospital, no personalized infant care checklist/schedule for infant care at home, failure to identify pediatrician prior to discharge and information overload at the time of discharge as potential barriers.  

Conclusion:The barriers identified were multifactorial and included lack of standardized discharge processes, poor communication and coordination among providers and parents, disconnect between EHR system and no formal parental training of DME. In addition to healthcare providers, parents are important stakeholders in caring for infants at home post NICU discharge and their perspective is crucial to successful transition to home of NICU graduates. We plan to use this information to help develop a transition to home program for parents of NICU graduates with the goal of reducing unplanned healthcare utilization following discharge.

 

98.06 Home Disposal Kits for Excess Opioid and Non-Opioid Pain Medications After Surgery: Do they work?

Posted on January 31, 2019

S. M. Stokes1, A. C. Jacobs2, B. S. Brooke4, E. Jordan1, A. C. Kwok3, R. Glasgow1, T. K. Varghese5, L. C. Huang1  1University Of Utah,Department Of Surgery, Division Of General Surgery,Salt Lake City, UT, USA 2University Of Utah,School Of Medicine,Salt Lake City, UT, USA 3University Of Utah,Department Of Surgery, Division Of Plastic Surgery,Salt Lake City, UT, USA 4University Of Utah,Department Of Surgery, Division Of Vascular Surgery,Salt Lake City, UT, USA 5University Of Utah,Department Of Surgery, Division Of Cardiothoracic Surgery,Salt Lake City, UT, USA

Introduction: Post-operative patients often have excess opioid and non-opioid pain medications after surgery. Many patients save these medications for later use or divert them to family and friends. Patients are encouraged to properly dispose of excess medications at drug take-back days or at DEA-approved disposal sites but these options require significant initiative. We hypothesized that a convenient home disposal kit will result in more appropriate disposal of excess medications.

Methods: We conducted a prospective cohort study at a single academic institution to identify patient practices regarding excess pain medications left over following a variety of surgical procedures. Procedures included general, breast, colorectal, foregut, vascular, and plastic surgery procedures. Patients were divided into two groups — those who received a home disposal kit and an educational handout, and those who did not. At the first follow-up visit, patients completed a survey in which they recorded the amount of pain medications remaining and what they had done or planned to do with their excess medications. Patients were also asked about risk factors for chronic opioid use. We used multivariable linear and logistic regression to identify independent factors associated with lower patient-reported likelihood to dispose of pain medications. 

Results:The survey was administered to 346 patients with a response rate of 84% (289 responses). Of the 289 respondents, 15% did not use opioids after surgery, as they were not prescribed opioids or did not fill their prescription. The survey was completed a median of 17 days (IQR 13-27 days) after discharge. Overall, 113 patients (40.5%) reported taking all of their prescribed pain medications. Of the 121 (42%) who still had excess pain medications, 14% reported ongoing need, 39% reported keeping the medications for future use, and 36% reported the intention to dispose of their medications. 50 patients (17.7%) received a home disposal kit. Among patients disposing of medications and received a kit, 84% used it, 17% disposed of it by the garbage/toilet, and 0% used other methods. In the group that did not receive the disposal kit, 16% were interested in a kit, but other methods were highly variable — opioid disposal location (38%), toilet/garbage (16%), opioid takeback program (22%), and other (9%). However, the proportion of patients disposing of medications did not change between those who received the kit (31.6%) and those who did not (34%, p = 0.486). No factors were identified during multivariable analysis that increased a patient’s likelihood for disposal.

Conclusion: Use of the home disposal kit was high among those intending to dispose of excess medications, suggesting that it was easier to use than other methods. However, distribution of the kit and handout was not sufficient to encourage more patients to choose disposal. Further research is needed on effective strategies for better medication stewardship.

 

98.05 Early Qualitative Outcomes of Clean Cut, a Lifebox Surgical Safety Improvement Program in Ethiopia

Posted on January 31, 2019

A. Mattingly1, N. Starr2,3, S. Bitew3, J. A. Forrester3,5, S. Bereknyei Merrell6, T. Mammo7, T. G. Weiser3,5  1Stanford University,Palo Alto, CA, USA 2University Of California – San Francisco,Department Of Surgery,San Francisco, CA, USA 3Lifebox Foundation,Boston, MA, USA 5Stanford University,Department Of Surgery,Palo Alto, CA, USA 6Stanford University,Department Of Surgery, S-SPIRE,Palo Alto, CA, USA 7Addis Ababa University,Department Of Pediatrics Surgery,Addis Ababa, Ethiopia

Introduction:  Clean Cut is a quality improvement intervention focusing on key perioperative infection prevention standards currently being implemented in Ethiopia. Developed by Lifebox, a non-profit dedicated to improving surgical safety, Clean Cut engages surgeons, nurses and anesthesia providers to identify and improve perioperative processes. In order to refine the implementation framework, we interviewed providers to better understand the benefits and challenges of implementing this program.

Methods:  We conducted a qualitative study using semi-structured interviews of staff perspectives on hospitals’ baseline performance, implementation barriers and facilitators, process improvement strategies, and sustainability. After obtaining consent, 20 Clean Cut team members (surgeons, nurses, anesthetists and managers) were interviewed. Audio recordings were transcribed, coded for themes, and analyzed using Dedoose software. Stanford University IRB approved the study.

Results: Major themes across all sites were the ability to enact perioperative process changes, enumeration of barriers to implementation, and strategies for improving adherence to surgical safety standards. Process changes focused on improving the appropriate use of the Surgical Safety Checklist (SSC), routine use of sterility indicators, discarding faulty gowns and drapes, and improved timing of prophylactic antibiotic administration. Challenges included lack of material resources such as computers and paper for data entry, functional autoclaves, sterile indicators, alcohol hand rub, and consistent running water. Payment for data collection affected motivation and incentives; non Clean Cut staff associated SSC completion and follow up as the responsibility of those who were being paid, rather than an inheret part of the job. Checklist completion led to increased perceived accountability that had both negative (fear of punishment) and positive (feelings of reassurance) effects. Benefits of implementation included perceived permanent changes in surgical practices: participants expressed improved self-reported patient satisfaction, incorporation of SSI education at discharge and increased training for staff on infection rates. Strategies for successful implementation included incorporating checklist interventions into routine OR behavior through evidence-based training and one-on-one conversations to overcome resistors.

Conclusion: Despite major barriers to implementation including lack of materials and staff resistance, Clean Cut was effective at producing changes in perioperative infection prevention practices. Expansion must consider an individualized approach to change longstanding surgical practices and motivate staff with evidence-based trainings. We identified a need for increased education to disseminate quantitative findings beyond Clean Cut participants, and a need for a new strategy of efficient data collection that minimizes payment conflicts.

98.04 Patient Preferences for Disclosure of Other Physicians’ Errors

Posted on January 31, 2019

A. G. Antunez1, A. Saari1, J. Miller1, R. Jagsi1, J. B. Dimick1, L. A. Dossett1  1University Of Michigan,Ann Arbor, MI, USA

Introduction:
Patients prefer physicians to disclose their self-discovered medical errors, and disclosure expectations and practices have changed accordingly. Patient preferences when physicians discover another provider’s error are unknown. Inter-facility medical error discovery (I-MED) describes scenarios where a medical error is (1) discovered by a provider in a facility different from the one in which it occurred and (2) not known to the responsible provider. Previous work has shown that physicians struggle, and often fail, to fully disclose these errors to patients. This study analyzes patients’ preferences around disclosure in cases of I-MED.

Methods:
We conducted telephone interviews beyond thematic saturation (n=30) from January to March 2018 with patient volunteers in Michigan. Three investigators conducted interviews following a semi-structured guide based on a hypothetical medical error case scenario. Interviews were conducted concurrently with thematic coding, coded independently by two investigators, and discussed until consensus was reached. Analysis proceeded following the inductive and comparative approach of interpretive description.

Results:
Patients considered I-MED functionally equivalent to self-discovered errors, and strongly preferred disclosure in both scenarios. Patients preferred disclosure for a variety of reasons, most commonly describing an inherent value in knowing about their own health, a desire to participate in future care in an informed manner, and a belief that doctors should practice honesty and transparency. The only exceptions to this preference for disclosure were instances of small errors with no impact on patients’ well-being. Patients reported that their trust in the discovering physician would be dramatically reduced if they later found that physician had concealed the responsible physician’s error, rather than disclosing it. Patients said they would likely take certain actions after disclosure of another physician’s error, ranging from confronting the responsible physician to changing providers to pursuing legal action, with the latter being only in cases of debilitating, irreversible errors. All of these findings were mediated by circumstance, with subjects often being empathetic to physicians’ justifications for hesitating to disclose others’ errors, while still emphasizing that they prioritize error disclosure (Table 1).   

Conclusion:
This study explores a new domain within the field of error disclosure, concluding that patients almost always preferred disclosure of errors in cases of I-MED. Physicians’ concerns that patients may be distressed or pursue legal action following disclosure are not unfounded.  Notably, as long as errors are disclosed transparently and are not especially egregious, patients expressed an emphasis on future care, not on punitive measures. Overall, these findings provide a convincing impetus to devise systems-level solutions to enable I-MED disclosure, possibly via increased medico-legal partnerships and novel channels to address inter-facility errors.

98.03 Variation in Hernia Technique Selection for Abdominal Wall Hernia Repairs

Posted on January 31, 2019

C. A. Vitous1, S. M. Jafri1, C. Seven1, M. Novitsky1, J. B. Dimick1,2, D. A. Telem1,2  1University Of Michigan,Center For Healthcare Outcomes And Policy, Institute For Healthcare Policy And Innovation,Ann Arbor, MI, USA 2University Of Michigan,Department Of Surgery,Ann Arbor, MI, USA

Introduction: While variation in the technique of abdominal wall hernia repair is widely accepted, it is poorly characterized. Although it is known that a great deal of this variation is based on surgeon and patient factors, how these factors influence the decision-making process remains unclear. In this context, we sought to gain an in-depth understanding of the factors that motivate decision making for surgeons. In order to do this, we explored areas of agreement and disagreement, or concordance and discordance, in decision-making patterns using common clinical case scenarios.

Methods: The data in this abstract is based on 6 qualitative clinical vignettes that were conducted with 21diverse, practicing surgeons who practice abdominal wall hernia repairs in a variety of institutional and geographic settings across the state of Michigan. Clinical vignettes were designed to capture the approach to controversial areas in abdominal wall hernia repair involving patient (e.g., obesity, smoking status, diabetes, age) and hernia (e.g., size, location, symptoms) factors. Through thematic analysis, using NVivo (version 11.4.3), we located, analyzed, and reported patterns within the data.

Results: Thematic analysis demonstrated a wide variety of decision-making patterns in the following 3 main domains: 1) surgeon willingness to perform elective repair, 2) surgeon preference for open, laparoscopic, or robotic repair, and 3) thresholds for contingent factors. Areas of little variation, or great concordance, were found in approaches to active tobacco users, with all surgeons utilizing a minimally invasive approach for repairs and avoiding an open approach. Additionally, concordance was found in the practice of discouraging patients from pursuing surgical interventions for small hernias (.5cm), instead placing patients on watchful criteria. Areas of discordance were far more prevalent in the clinical case scenarios presented to participants. To begin, significant variation was found in surgeon willingness to perform elective repairs on patients with confounding health risks, including uncontrolled diabetes, active tobacco use, and obesity. Further, in instances where surgeons were willing to perform elective repairs, significant differences emerged in the acceptable parameters for contingent factors, such as obesity, smoking cessation requirements, and glycemic levels. Finally, variation was found in approaches for large defects, with significant difference found in the upper size limits for utilizing a minimally invasive approach. Factors that influenced variation were wide-ranging, but included a preference for approach based on surgeon experience/training (both formal and informal), patient preference, and environmental considerations, such as the size of the hospital, geographic location, and whether the institution was private or public.

Conclusion: All of the clinical scenarios revealed at least some level of discordance in practice patterns motivated by individual surgeon preference and environmental considerations, rather than evidence based guidelines. These novel findings understanding the motivations and behaviors driving patient and technique selection will be invaluable to the design of evidence based interventions to decrease variability and promote evidence-based practice in abdominal wall hernia repair.

 

98.02 A Qualitative Analysis of Clinicians from the Paris, Brussels, and Boston Mass Casualty Incidents

Posted on January 31, 2019

E. Goralnick1,2,3,4, R. Sarin2,5, C. Ezeibe3,4, S. Loo6, P. Halpern7, R. Serino4, E. McNulty4, L. Marcus4, G. Ortega3,4, K. Peleg7  1Brigham And Women’s Hospital,Department Of Emergency Medicine,Boston, MA, USA 2Harvard School Of Medicine,Department Of Emergency Medicine,Brookline, MA, USA 3Brigham And Women’s Hospital,Center For Surgery And Public Health,Boston, MA, USA 4Harvard School Of Public Health,Boston, MA, USA 5Beth Israel Deaconess Medical Center,Department Of Emergency Medicine,Boston, MA, USA 6Boston University,School Of Public Health,Boston, MA, USA 7Tel Aviv University,Tel Aviv, Israel

Introduction:  Recent mass casualty incidents (MCI) have highlighted the need for clinicians to integrate MCI planning into their emergency management preparations. Current sharing of MCI knowledge is limited to anecdotal after-action reports with limited ability to compare events systematically and improve practices. Our aim was to pilot a qualitative tool with clinicians from three recent urban terror events to capture common themes, best practices, and unresolved challenges during MCIs. This could then be used to create a standardized after-action report to populate a database to aid in improving MCI patient care.

Methods:  A qualitative study was performed in two stages. First, two in-person focus groups were conducted utilizing Poll Everywhere© to solicit initial perspectives, as well as additional comments regarding the experience of clinicians from the following MCIs: Boston (April 2013), Paris (November 2015), and Brussels (March 2016). Data collected was qualitatively analyzed by two investigators who then designed semi-structured interview guides, used to conduct key informant interviews. These interviews were recorded, transcribed, and coded. Content analysis was used to identify emergent themes.

Results: Overall, 14 individuals participated in two focus groups and 11 participated in follow up interviews. There were five overarching themes that emerged from our analysis: 1) exercises and training, 2) military to civilian translation, 3) personnel management, 4) planning for failure and 5) recovery to normal operations. While each theme highlighted both strengths and improvement opportunities, all participants identified that recovery was the most challenging phase. Psychological impacts, either lack of or variability in debriefing, and patient identification were each identified as key recovery gaps across all three MCI sites.

Conclusion: To advance disaster preparedness, common themes can be identified across multiple MCIs to clarify best practices and gaps to target future innovation. Although immediate response is often highlighted anecdotally, the recovery phase warrants further focus and investigation to improve quality of care during disasters.
 

98.01 Clinician-to-Clinician Communication Of Patient Goals Of Care Within A Surgical Intensive Care Unit

Posted on January 31, 2019

B. V. Udelsman1, K. Lee2,4, L. Traeger3, K. Lillemoe1, D. Chang1, Z. Cooper2  1Massachusetts General Hospital,Surgery,Boston, MA, USA 2Brigham And Women’s Hospital,Surgery,Boston, MA, USA 3Massachusetts General Hospital,Cancer Center And The Behavioral Medicine Service,Boston, MA, USA 4University of California San Diego,Department Of Surgery,San Diego, CA, USA

Introduction:  Little is known about the process by which inpatient teams document and convey goals of care (GOC) for critically ill surgical patients.  We sought to explore clinician perspectives on the barriers and facilitators to clinical team communication and delivery of goal-concordant patient care.

Methods:  Purposive and snowball sampling were used to recruit a multi-disciplinary sample of clinicians who had roles in a surgical intensive care unit at a single tertiary care facility.  Semi-structured interviews with clinicians regarding communicating and honoring patient GOC were conducted between October and December 2017. Two study team members independently coded the interview transcripts in an iterative fashion based on a framework approach.  Inter-rater agreement measured by kappa, and was acceptably high at 0.91.

Results: Thirty-three clinicians were interviewed: eight surgeons, eight nurses, seven anesthesiologists/intensivists, five mid-level providers, three residents, and two social workers.  Of the surgeons, four completed fellowship in trauma/acute care, two in surgical oncology, one in vascular surgery, and one in cardiothoracic surgery.  Analysis revealed that all clinicians feel responsible for honoring patient GOC.  The process of GOC communication among inpatient teams occurs in three distinct phases.  (1) A discussion takes place between clinicians and the patient or their surrogates;  (2) clinicians document that conversation within the electronic health record;  (3) inpatient teams read GOC documentation in order to inform treatment and provide goal concordant care.  Within these phases of GOC communication, six themes emerged that described both facilitators and barriers to the communication of GOC among clinicians and delivery of goal concordant care (Table 1). Conflicts over patient GOC arose between clinicians who had longitudinal relationships with patients (pre-operative and post-operative) versus those who had single-phase relationships (post-operative).  Barriers to clinician-to-clinician communication and delivery of goal-concordant care included inaccessible records, lack of protocols, and difficulty in documenting complex conversations.  Facilitators included family members in active agreement with patient GOC and a clinician understanding of unique patient priorities.

Conclusion: Differences in the longitudinal clinician-patient relationship and difficulty accessing information about patient preferences contribute to clinician conflicts and concerns with the appropriateness of patient care.  These themes exist over multiple phases of patient care and represent areas of focus for quality improvement.

 

 

97.20 Prenatal Dilated Rectum: Do We Need to Worry?

Posted on January 31, 2019

A. G. Kim1,2, D. R. Berman2,3, J. Kreutzman2,3, M. C. Treadwell2,3, G. B. Mychaliska1,2, E. E. Perrone1,2  1University Of Michigan,Department Of Surgery, Section Of Pediatric Surgery,Ann Arbor, MI, USA 2University Of Michigan,Fetal Diagnosis And Treatment Center,Ann Arbor, MI, USA 3University Of Michigan,Department Of Obstetrics And Gynecology, Division Of Maternal-Fetal Medicine,Ann Arbor, MI, USA

Introduction:
Advances in prenatal imaging results in increasing detection of abnormally dilated bowel.  There is no literature to date focusing on the clinical significance of a dilated rectum.  We hypothesized that the majority of antenatally identified cases of a dilated rectum are normal variants, but certain characteristics may be more often associated with pathology. 

Methods:
A retrospective chart review was performed on all patients in whom “dilated bowel” was identified on prenatal ultrasound between January 2000 and December 2017 at a single institution, excluding cases of prenatally diagnosed ventral wall defects.  Data including diagnoses, surgeries, and outcomes were collected.  Descriptive statistics were used.

Results:
193 cases of “dilated bowel” were identified in which 12 (6.2%) had specifically visualized a dilated or prominent rectum.  Nine of these (75.0%) had no rectal or intestinal abnormality on postnatal evaluation and were discharged feeding and defecating normally.  Three cases required further work-up and management in the neonatal period: 1) meconium plug, 2) jejunal atresia with cecal perforation, and 3) rectal perforation with retroperitoneal abscess.  All three had rectal biopsies with identification of ganglionated submucosa.     

Conclusion:
Although a prenatally dilated rectum is a normal variant in the majority of cases, it may be associated with a gastrointestinal abnormality requiring surgical intervention.  Interestingly, there were no cases of Hirschsprung’s disease in this cohort.  These results in conjunction with continued efforts to identify and measure rectal and large bowel dilation are useful for prenatal counseling and postnatal evaluation.
 

« Previous Page
Next Page »