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Background Despite unprecedented changes to undergraduate medical education and the residency selection process during the COVID-19 pandemic, there is little objective evidence on how the pandemic impacted match outcomes such as matched applicant characteristics, interview distribution, geographic clustering, and associated costs. We investigated COVID-19’s impact on the residency match by comparing surgery applicants’ characteristics, interview distribution, and related costs from 2018-2020 to 2021. Methods Data from the Texas Seeking Transparency in Applications to Residency (STAR) initiative were analyzed. Descriptive statistics, bivariate testing, and sensitivity analysis were performed to compare matched applicants in surgical specialties from 2018-2020 to 2021. Results This study included 5,258 applicants who matched into ten surgical specialties from 2018-2021. In 2021, there was a decrease in proportion of students who reported a geographic connection to their matched program (38.4% vs. 42.1%; p=0.021) and no significant difference in number of interviews attended (mean (SD), 13.1 (6.2) vs. 13.3 (4.7); p=0.136) compared to prior years. Applicants in 2021 had more research experiences and fewer honored clerkships (both p, Graphical abstract, We investigate COVID-19’s impact on residency applicants by comparing matched surgery applicants’ characteristics, interview invitation and attendance patterns, and interview-associated costs from match years 2018-2020 to match year 2021. The importance of this report is providing a better understanding of the adoption of virtual interviews and virtual away rotations in preparation for future match cycles.

Background Racial disparities in opioid prescribing are widely documented, though few studies assess racial differences in the postoperative setting specifically. We hypothesized standard opioid prescribing schedules reduce total opioids prescribed postoperatively and mitigate racial variation in postoperative opioid prescribing. Methods This is a retrospective review of adult general surgery cases at a large, public academic institution. Standard opioid prescribing schedules were implemented across general surgery services for common procedures in late 2018 at various timepoints. Interrupted time series analysis was used to compare mean biweekly discharge morphine milligram equivalents prescribed in the preintervention (Jan–Jun 2018) versus postintervention (Jan–Jun 2019) periods for Black and White patients. Linear regression was used to compare mean difference in discharge morphine milligram equivalents among White and Black patients in each study period, while controlling for demographics, chronic opioid use, and procedure/service. Results A total of 2,961 cases were analyzed: 1,441 preintervention and 1,520 postintervention. Procedural frequencies, proportion of Black patients (17% Black), and chronic opioid exposure (7% chronic users) were similar across time periods. Interrupted time series analysis showed significantly lower mean level of morphine milligram equivalents prescribed postintervention compared with the predicted nonintervention trend for both Black and White patients. Adjusted analysis showed on average in 2018 Black patients received significantly higher morphine milligram equivalents than White patients (+19 morphine milligram equivalents, 95% confidence interval 0.5–36.5). There was no significant difference in 2019 (–8 morphine milligram equivalents, 95% confidence interval –20.5 to 4.6). Conclusion Standard opioid prescribing schedules were associated with the elimination of racial differences in postoperative opioid prescribing after common general surgery procedures, while also reducing total opioids prescribed. We hypothesize standard opioid prescribing schedules may mitigate the effect of implicit bias in prescribing.

Background Melanoma-specific outcomes for Black patients are worse when compared to non-Hispanic white (NHW) patients. We sought to evaluate whether acral lentiginous melanoma, seen more commonly in Black patients, was associated with racial disparities in outcomes Methods The National Cancer Database was analyzed for major subtypes of stage I-IV melanoma diagnosed from 2004 to 2016. The association between Black race and (Siegel et al., Jan) 1 acral melanoma diagnosis and (Bradford et al., Apr) 2 receipt of major amputation for surgical management of melanoma was evaluated using multivariable logistic regression. Results 251,864 patients were included (1453 Black). Black patients had increased odds of acral melanoma (odds ratio [OR] = 27.6, 95% CI]: 24.4, 31.2) compared to NHW patients. Black patients still had higher odds ratios of major amputation across all stages after adjusting for acral histology and other potential confounders Conclusions Increased prevalence of acral melanoma in Black patients does not fully account for increased receipt of major amputation.

Radiation therapy often requires weeks of daily treatment making travel distance a known barrier to care. However, the full extent and variability of travel burden, defined by travel time, across the nation is poorly understood. Additionally, some states restrict radiation oncology (RO) services through Certificate of Need (CON) policies, but it is unknown how this affects travel times to care. Therefore, we aim to evaluate travel times to US RO facilities and assess the association with CON policies.RO facilities were identified from the 2018 National Plan and Provider Enumeration System (n = 2302). Travel times from populated US census tracts to nearest facility were calculated; differences by rurality, area deprivation, and region were computed. Multivariable linear regression was used to estimate adjusted differences in travel time by area characteristics. Logistic regression was used to assess the association of state CON laws with travel time1 hour.Among 72,471 census tracts, 92.4% were within 1 hour of the nearest radiation facility. Among the 12,453 rural tracts, 34.4% were1 hour. On adjusted analysis, the 3054 isolated rural tracts had an estimated 58-minute (95% confidence interval [CI] 57, 59; P.001) longer travel time than urban tracts. CON laws decreased rural travel time overall, but the association varied by region with decreased odds of prolonged travel in the South (P.001), increased odds in the Northeast and Midwest (P.001), and no association in the West (P = NS).Isolated rural US census tracts, accounting for 9.4 million Americans, have nearly 1-hour longer adjusted travel time to the nearest RO facility, compared with urban tracts. CON laws had region-dependent associations with prolonged travel.

Background Adult colorectal surgery patients continue to have high rates of readmissions, despite known risk factors for non-routine postdischarge care (emergency department (ED) visit or rehospitalization) and countless interventions to address these. It is unclear how the difficult-to-quantify patient perspective frames and modifies the impact of these quantifiable risk factors. Study design We identified consecutive adult inpatient colorectal surgery patients from 2017 to 2018. This mixed methods study merged data from electronic health records and in-depth patient interviews. Results We enrolled 258 participants, surveyed 167, and interviewed 18. Depressive symptoms represent one of many risk factors confirmed to increase non-routine healthcare utilization (RR 1.85, 95% CI 1.02–3.37), though the patient perspective explained why these symptoms seemed to greatly impact some patients more than others. Additionally, consistent with patient report, patients with non-routine postdischarge care (26%) were less likely to report communication with their surgical team (80% vs 97%, p Conclusion Patient perspectives add depth and understanding of the impact of risk factors on non-routine post-discharge care. This expanded knowledge explains why one patient is more likely to visit an ED close to home whereas another patient might prefer to visit their surgeon’s clinic directly. Effective strategies to reduce unplanned postdischarge care should be tailored.

Few studies examine outcomes by surgical approach in non-small-cell lung cancer (NSCLC) with N2 disease. We examined time trends in surgical approach and outcomes among patients undergoing minimally invasive (MIS, robotic and video-assisted thoracoscopic surgery [VATS]) vs open lobectomy in this patient population. We performed a retrospective analysis of patients from the National Cancer Database diagnosed with clinical Stage IIIA-N2 NSCLC from 2010 to 2016. We examined the yearly proportion of MIS vs open resections. Multivariable regression was used to assess the association of surgical approach with length of stay, unplanned readmissions, 30-day and 90-day mortality. Multivariable Cox proportional hazards modeling was used to assess the association of surgical approach with 5-year overall mortality. We identified 5741 patients who underwent lobectomy for Stage IIIA-N2 NSCLC (459 robotic, 1403 VATS, 3879 open). From 2010 to 2016, the proportion of minimally invasive procedures increased from 20% to 45%. MIS patients, on average, stayed 1 day less in the hospital (95% confidence interval [CI] 0.7, 1.5) and had lower odds of 90-day (odds ratio [OR] 0.74; 95% CI 0.54, 0.99) and 5-year mortality (OR 0.82; 95% CI 0.75, 0.91), compared to open resections. There was no difference in odds of readmission by surgical approach (OR 0.97; 95% CI 0.71, 1.33). Among MIS procedures, robotic resections had lower odds of 90-day mortality (OR 0.42; 95% CI 0.18, 0.97) than VATS. Among patients undergoing lobectomy for locally advanced N2 NSCLC robotic and VATS techniques appear safe and effective compared to open surgery and may offer short- and long-term advantages.

Background: Adult colorectal surgery patients continue to have high rates of readmissions, despite known risk factors for non-routine postdischarge care (emergency department (ED) visit or rehospitalization) and countless interventions to address these. It is unclear how the patient perspective frames and modifies the impact of these risk factors. This study aimed to explain why individual risk-factors led a patient to seek non-routine postdischarge care. Methods: This single institution prospective cohort study identified consecutive adult inpatient colorectal surgery patients from 2017-2018. We used a convergent parallel design to integrate electronic health record data with brief phone surveys and in-depth interviews to generate a “what, why, and so what” summary of findings. Findings: We enrolled 258 participants, surveyed 167, and interviewed 18. Overall, 20% were readmitted, 3% had an ED visit, 2% had an observation stay, and 75% had routine postdischarge care. Undergoing open surgery (RR 2.25, 95% CI 1.31-3.87) and reporting depressive symptoms (RR 1.85, 95% CI 1.02-3.37) were associated with an increased non-routine healthcare utilization. Whereas, each 10 miles increasing travel distance (RR 0.94, 95% CI 0.90-0.98), private insurance (RR 0.61 , 95% CI 0.40-0.93), and proactively scheduled follow-up appointments (RR 0.43, 95% CI 0.27-0.69) were protective factors. Patients with non-routine postdischarge care (26%) were less likely to report communication with their surgical team (80% vs 97%, p

Objective To estimate variation in the use of neoadjuvant chemotherapy by high volume hospitals and to determine the association between hospital utilization of neoadjuvant chemotherapy and survival. Methods We identified incident cases of stage IIIC or IV epithelial ovarian cancer in the National Cancer Database from 2006 to 2012. Inclusion criteria were treatment at a high volume hospital (> 20 cases/year) and treatment with both chemotherapy and surgery. A logistic regression model was used to predict receipt of neoadjuvant chemotherapy based on case-mix predictors (age, comorbidities, stage etc). Hospitals were categorized by the observed-to-expected ratio for neoadjuvant chemotherapy use as low, average, or high utilization hospitals. Survival analysis was performed. Results We identified 11,574 patients treated at 55 high volume hospitals. Neoadjuvant chemotherapy was used for 21.6% (n = 2494) of patients and use varied widely by hospital, from 5%–55%. High utilization hospitals (n = 1910, 10 hospitals) had a median neoadjuvant chemotherapy rate of 39% (range 23–55%), while low utilization hospitals (n = 2671, 14 hospitals) had a median rate of 10% (range 5–17%). For all ovarian cancer patients adjusting for clinical and socio-demographic factors, treatment at a hospital with average or high neoadjuvant chemotherapy utilization was associated with a decreased rate of death compared to treatment at a low utilization hospital (HR 0.90 95% CI 0.83–0.97 and HR 0.85 95% CI 0.75–0.95). Conclusions Wide variation exists in the utilization of neoadjuvant chemotherapy to treat stage IIIC and IV epithelial ovarian cancer even among high volume hospitals. Patients treated at hospitals with low rates of neoadjuvant chemotherapy utilization experience decreased survival.

Objectives To assess regionalization trends and short-term clinical outcomes in patients undergoing radical cystectomy for urothelial carcinoma. Materials and methods Using 1996–2009 discharge data from New York (NY), New Jersey (NJ) and Pennsylvania (PA), all patients ≥18 years with urothelial carcinoma undergoing cystectomy were identified using ICD-9 coding. We assigned hospital volume status by quintiles based on relative proportions of cystectomies performed on a per hospital basis in 1996; very low volume hospitals: 0–2 (VLVH), low: 3–4 (LVH), moderate: 5–8 (MVH), high: 9–31 (HVH), and very high: ≥32 (VHVH). Changes in the proportion of procedures performed by volume categories were assessed over time, and patient characteristics were compared between groups. Results A total of 14,404 patients met inclusion criteria. For each year increase from 1996 to 2009, the odds of having surgery performed at a VHVH increased by 22% (odds ratio [OR] 1.22, confidence interval [CI] 1.04–1.44). Patients undergoing surgery at a VHVH were less likely to be African American (OR 0.59 [CI 0.39–0.91]), or insured through Medicaid (OR 0.65 [CI 0.50–0.84]) or Medicare (OR 0.84 [CI 0.75–0.94]). Controlling for year treated, total procedures performed, and patient characteristics, median hospital length of stay (HLOS) was shorter (median difference −0.89 days [CI −1.12 to −0.66]), and patients were significantly less likely to die during their hospital stay if treated at a VHVH compared with a VLVH (OR 0.33 [CI 0.22–0.49]). Conclusions There has been extensive regionalization of cystectomy to VHVHs in NY, NJ, and PA since 1996. Despite apparent improvements in mortality and HLOS in patients treated at higher volume centers in our sample, future investigations more rigorously adjusting for hospital structural characteristics and patient severity are necessary to confirm these findings. Disparities in access to VHVH care are still evident and must be addressed.

Background Melanoma care is becoming increasingly multidisciplinary, requiring coordination of many types of providers. The purpose of this study is to describe the structure of melanoma care in North Carolina by examining services provided by different providers and the overall coordination of care. Methods Self-administered surveys were developed to collect demographic and practice information, assess patient volume and services provided, and explore referral patterns. Surveys were administered to all dermatologists and a subset of surgeons practicing in North Carolina. Results The response rate was 60% (263/438). Melanoma patient volume, referral patterns, use of nodal staging, and access to clinical trials were each related to provider characteristics, specialty, affiliations with cancer care organizations, and practice setting. Conclusions Many types of providers contribute significantly to the care of melanoma patients. Coordination between providers is variable. This study provides indirect evidence that multidisciplinary melanoma programs increase patient access to comprehensive melanoma care.