Search

Introduction: Despite being one of the most commonly performed operations in the US, there is a paucity of data on practice patterns and resultant long-term outcomes of groin hernia repair. In this context, we performed a contemporary assessment of operative approach with 5 year follow-up to inform care for the 800000 persons undergoing groin hernia repair annually., Methods: This was a retrospective cohort study of adult patients undergoing elective groin hernia repair in a 20% representative Medicare sample from 2010-17. Surgical approach [minimally invasive (MIS) vs open] was defined using appropriate CPT codes. The primary outcome was operative recurrence at up to 5 years following surgery. We estimated the overall risk of operative recurrence using a multivariable Cox proportional hazards model., Results: Among 118119 patients, the majority (76.4%) underwent an open repair. Compared to patients who underwent MIS repair, patients in the open surgery cohort were older (mean age 72.7 vs 71.0, p < 0.001), more often female (14.4 vs 10.9%, p < 0.001), less often white (86.9 vs 87.7%, p < 0.001), and had a higher prevalence of nearly all measured comorbidities Patients in the open cohort had a lower incidence of operative recurrence at 1-year (1.0 vs 1.5%, p < 0.001), 3-years, (2.5 vs 3.5%, p < 0.001), and 5-years (3.7 vs 4.7%, p < 0.001). In the Cox proportional hazards model, we found that patients who underwent an open groin hernia repair were significantly less likely to experience operative recurrence (HR 0.86, 95% CI 0.79-0.93)., Conclusions: In this study, we found that open groin hernia repair was associated with a lower risk of operative recurrence over time. While this may be related to patient comorbidity and age at the index operation, future work should focus on the impact of surgeon volume on outcomes in the modern era., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Purpose: Although incivility has been described in other specialties, little is known about the attributes and perpetrators of it in academic surgery. The goal of this study was to identify attributes and commonly associated perpetrators of incivility experienced by trainees and faculty at academic surgery programs in the U.S., Methods: A web-based survey including the Workplace Incivility Scale (WIS) and questions regarding attributions and perpetrators of incivility was sent to trainees and faculty at academic institutions across the U.S. In addition to descriptive statistics, multivariable regression models were built to determine the impact of perpetrator type and number on overall incivility scores., Results: We received 367 of 2,661 (13.8%) responses. Top three reasons for incivility were surgery hierarchy (50.1%), respondent's gender (33.8%) and intergenerational differences (28.1%). Faculty (58.6%), patients (36.8%), and nursing staff (31.9%) were the most reported parties responsible for incivility. Female surgeons reported experiencing incivility more frequently from all three top responsible parties (i.e., faculty, patients, and nurses) when compared to other gender identities. Additionally, those who reported faculty ( β  = 0.61, 95%CI 0.39-0.82) or nurses ( β  = 0.23, 95%CI 0.009-0.45) as perpetrators of incivility reported an increase in overall incivility scores., Conclusions: Incivility in surgery is frequently attributed to surgery hierarchy, gender, and intergenerational differences. Surgical trainees and faculty reported that faculty, patients, and nurses were the most commonly identified as responsible for uncivil events in the surgical workforce. Exposure to a greater variety of perpetrators of incivility increases overall levels of incivility, emphasizing the importance of eliminating incivility from all sources., Supplementary Information: The online version contains supplementary material available at 10.1007/s44186-023-00129-1., Competing Interests: Conflict of interestThe authors have no relevant financial or non-financial interests to disclose., (© The Author(s), under exclusive licence to Association for Surgical Education 2023, Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.)

Purpose: Females suffer higher rates of operative recurrence and chronic pain following groin hernia repair. Guidelines recommend minimally invasive (MIS) groin hernia repair as the preferred approach to reduce these adverse outcomes. It is unknown what proportion of females receive MIS hernia repair. Therefore, our goal was to investigate adoption of evidence-based practices in groin hernia repair using sex as a biological variable., Methods: Retrospective cohort study of adults undergoing elective groin hernia repair (2014-2019) within a statewide quality improvement collaborative. Primary outcome was surgical approach. Multivariable logistic regression was performed to analyze the likelihood of undergoing MIS hernia repair. Secondary outcomes were 30-day adjusted rates of clinical and patient-reported outcomes (PROs). PROs included regret to undergo surgery among patients who completed post-operative surveys., Results: Among 23,723 patients, the majority (90.7%) were males. Compared to males, females less often underwent an MIS surgical approach (37.4% vs 45.1%, p < 0.0001). After adjustment for patient and clinical variables, females remained significantly less likely to undergo MIS groin hernia repair (aOR 0.88, 95% CI 0.80-0.97). Adjusted clinical outcomes were not different between males and females. Among 4325 patients who completed post-operative surveys, adjusted rates of regret to undergo surgery were higher among females (12.9% vs 8.5%, p = 0.003)., Conclusions: Even after adjusting for differences, females were less likely to receive guideline-concordant groin hernia repair and were more likely to regret surgery. Understanding the behaviors of surgeons who treat females with groin hernia may inform quality metrics to promote best practices in this population., (© 2022. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Background: Despite increasing numbers of older adults undergoing surgery and the known risks of opioids, little is known about the potential association between opioid prescribing and serious falls and fall-related injuries after surgery., Objective: To determine the incidence and risk factors of serious falls and fall-related injuries after elective, outpatient surgery., Design: Retrospective cohort study of 20% national sample of Medicare claims among beneficiaries ≥ 65 years of age with Medicare Part D claims and who underwent elective outpatient surgery from January 1, 2009, through December 31, 2014., Participants: Opioid-naïve patients ≥ 65 years undergoing elective, minor, outpatient surgical procedures. The exposure was opioid prescription fills in the perioperative period (i.e., 30 days before up until 3 days after surgery) converted to total oral morphine equivalents (OME) over a period 30 days prior to and 30 days after surgery., Main Measures: Serious falls and fall-related injuries within 30 days after surgery, examined through Poisson regression analysis with reported fall and fall-related injury rates adjusted for potential confounders., Key Results: Among 44,247 opioid-naïve surgical patients, 76.3% filled an opioid prescription in the perioperative period. Overall, 0.62% of patients suffered a serious fall or fall-related injury within 30 days after surgery. Risk factors for serious falls or fall-related injuries after surgery included older age (80-84 years: RR 1.64, 95% CI 1.12-2.40; 85 years and older: RR 1.81, 95% CI 1.25-2.86), female sex (RR 3.04, 95% CI 2.29-4.05), Medicaid eligibility (RR 1.63, 95% CI 1.17-2.26), and higher amounts of opioids filled following surgery (≥ 225 OME: RR 2.29, 95% CI 1.72-3.07)., Conclusions: Serious falls after elective, outpatient surgery are uncommon, but correlated with age, sex, Medicaid eligibility, and the amount of opioids filled in the perioperative period. Judicious prescribing of opioids after surgery is paramount and is an opportunity to improve the safety of surgical care among older individuals.

Background: Prescribing naloxone to patients is a key strategy to prevent opioid overdoses, but little is known about the reach of naloxone prescribing., Objective: Determine patient factors associated with receiving naloxone and trends over time in patients with key overdose risk factors., Design: Retrospective observational study., Participants: Using the Clinformatics DataMart, a US-wide health insurance claims dataset, we compared adults who received opioids and naloxone (opioid+naloxone) from January 2014 to June 2017 with adults who received opioids without naloxone (opioids only), matched on gender, age ± 5 years, month/year of opioid fill, and number of opioid claims., Main Measures: Key patient-level opioid overdose risk factors included receipt of high-dosage opioids, concurrent benzodiazepines, history of opioid and other substance use disorders, and history of opioid overdose., Results: We included 3963 opioid+naloxone and 19,815 opioid only patients. Key factors associated with naloxone fills included high opioid daily dosage (50 to < 90 morphine milligram equivalents (MME): AOR = 2.43, 95% CI 2.15-2.76 and ≥ 90 MME: AOR = 3.94, 95% CI 3.47-4.46; reference: < 50 MME), receiving concurrent benzodiazepines (AOR = 1.27, 95% CI 1.16-1.38), and having a diagnosis of opioid use disorder (AOR = 1.56, 95% CI 1.40-1.73). History of opioid overdose was not associated with naloxone (AOR = 0.92, 95% CI 0.74-1.15). The percent of patients receiving naloxone increased, yet less than 2% of patients in any of the key overdose risk factor groups received naloxone by the last 6 months of the study period., Conclusions: Naloxone prescribing has increased and was more likely to be co-prescribed to patients with some risk factors for overdose. However, overall prescribing remains minimal. Additional efforts are needed across health systems to increase naloxone prescribing for patients at risk for opioid overdose.

In surgery, quality assessment encourages improved care delivery, better outcomes, and helps determine surgical efficacy. Quality is important from a patient, provider, payer, and policy maker standpoint. However, given the growth of outpatient procedures, expansion of surgical indications to enhance function, and the decline of perioperative morbidity and mortality, many traditional quality metrics, such as mortality, readmissions, and complications, may not fully capture quality. As such, patient-reported outcomes (PROs) can be used to complement the established clinical outcomes and describe surgical efficacy and quality from the patient's point of view. Generic and disease-specific PRO measures capture health-related quality of life, functional status, and pain. These measures permit a more holistic understanding of how surgery affects different aspects of a patient's health, augment other clinical outcomes, and are commonly used to determine efficacy in clinical trials. Moreover, our national reimbursement structure is currently evolving to include PROs for certain surgical conditions in measures of quality and with direct linkage to payments. Even so, there continues to be challenges in the implementation of PRO measures in everyday surgical practice, with questions of optimal administration and how to integrate these measures into provider work flow. Despite these challenges, PROs provide vital information regarding surgical efficacy and quality and are critical in the delivery of patient-centered care.

Background: Excessive opioid prescribing is common in surgical oncology, with 72% of prescribed opioids going unused after curative-intent surgery. In this study, we sought to reduce opioid prescribing after breast and melanoma procedures by designing and implementing an intervention focused on education and prescribing guidelines, and then evaluating the impact of this intervention., Methods: In this single-institution study, we designed and implemented an intervention targeting key factors identified in qualitative interviews. This included mandatory education for prescribers, evidence-based prescribing guidelines, and standardized patient instructions. After the intervention, interrupted time-series analysis was used to compare the mean quantity of opioid prescribed before and after the intervention (July 2016-September 2017). We also evaluated the frequency of opioid prescription refills., Results: During the study, 847 patients underwent breast or melanoma procedures and received an opioid prescription. For mastectomy or wide local excision for melanoma, the mean quantity of opioid prescribed immediately decreased by 37% after the intervention (p = 0.03), equivalent to 13 tablets of oxycodone 5 mg. For lumpectomy or breast biopsy, the mean quantity of opioid prescribed decreased by 42%, or 12 tablets of oxycodone 5 mg (p = 0.07). Furthermore, opioid prescription refills did not significantly change for mastectomy/wide local excision (13% vs. 14%, p = 0.8), or lumpectomy/breast biopsy (4% vs. 5%, p = 0.7)., Conclusion: Education and prescribing guidelines reduced opioid prescribing for breast and melanoma procedures without increasing the need for refills. This suggests further reductions in opioid prescribing may be possible, and provides rationale for implementing similar interventions for other procedures and practice settings.

Background: New persistent opioid use is a common postoperative complication, with 6% of previously opioid-naïve patients continuing to fill opioid prescriptions 3-6 months after surgery. Despite these risks, it is unknown which specialties prescribe opioids to these vulnerable patients., Objective: To identify specialties prescribing opioids to surgical patients who develop new persistent opioid use., Design, Setting, and Participants: Using a national dataset of insurance claims, we identified opioid-naïve patients aged 18-64 years undergoing surgical procedures (2008-2014) who continued filling opioid prescriptions 3 to 6 months after surgery. We then examined opioid prescriptions claims during the 12 months after surgery, and identified prescribing physician specialty using National Provider Identifier codes., Main Measures: Percentage of opioid prescriptions provided by each specialty evaluated at 90-day intervals during the 12 months after surgery., Key Results: We identified 5276 opioid-naïve patients who developed new persistent opioid use. During the first 3 months after surgery, surgeons accounted for 69% of opioid prescriptions, primary care physicians accounted for 13%, Emergency Medicine accounted for 2%, Physical Medicine & Rehabilitation (PM&R)/Pain Medicine accounted for 1%, and all other specialties accounted for 15%. In contrast, 9 to 12 months after surgery, surgeons accounted for only 11% of opioid prescriptions, primary care physicians accounted for 53%, Emergency Medicine accounted for 5%, PM&R/Pain Medicine accounted for 6%, and all other specialties provided 25%., Conclusions: Among surgical patients who developed new persistent opioid use, surgeons provide the majority of opioid prescriptions during the first 3 months after surgery. By 9 to 12 months after surgery, however, the majority of opioid prescriptions were provided by primary care physicians. Enhanced care coordination between surgeons and primary care physicians could allow earlier identification of patients at risk for new persistent opioid use to prevent misuse and dependence.

Background: Excessive opioid prescribing is common after curative-intent surgery, but little is known about what factors influence prescribing behaviors among surgeons. To identify targets for intervention, we performed a qualitative study of opioid prescribing after curative-intent surgery using the Theoretical Domains Framework, a well-established implementation science method for identifying factors influencing healthcare provider behavior., Methods: Prior to data collection, we constructed a semi-structured interview guide to explore decision making for opioid prescribing. We then conducted interviews with surgical oncology providers at a single comprehensive cancer center. Interviews were recorded, transcribed verbatim, then independently coded by two investigators using the Theoretical Domains Framework to identify theoretical domains relevant to opioid prescribing. Relevant domains were then linked to behavior models to select targeted interventions likely to improve opioid prescribing., Results: Twenty-one subjects were interviewed from November 2016 to May 2017, including attending surgeons, resident surgeons, physician assistants, and nurses. Five theoretical domains emerged as relevant to opioid prescribing: environmental context and resources; social influences; beliefs about consequences; social/professional role and identity; and goals. Using these domains, three interventions were identified as likely to change opioid prescribing behavior: (1) enablement (deploy nurses during preoperative visits to counsel patients on opioid use); (2) environmental restructuring (provide on-screen prompts with normative data on the quantity of opioid prescribed); and (3) education (provide prescribing guidelines)., Conclusions: Key determinants of opioid prescribing behavior after curative-intent surgery include environmental and social factors. Interventions targeting these factors are likely to improve opioid prescribing in surgical oncology.

Background: To make an informed choice, breast cancer patients facing surgery must imagine the effect of surgery on their future life experiences. However, the accuracy of patient predictions of postoperative quality of life (QoL) and disease-related stigma is not well understood., Materials and Methods: Four groups of breast cancer patients at the University of Michigan Medical Center were surveyed by mail and interview (response rate 76.3%): (1) preoperative (N = 59), (2) mastectomy (N = 146), (3) mastectomy with reconstruction (N = 250), and (4) breast conservation (N = 705). Subjects rated their QoL (1 = lowest, 100 = highest) and stigma (1 = lowest, 5 = highest) and estimated QoL and stigma associated with mastectomy alone, mastectomy with reconstruction, and breast conserving surgery (BCS). Mean scores were compared using linear regression controlling for age, race, partnered status, and income., Results: Preoperatively, women inaccurately predicted postoperative QoL and stigma for all surgical options, particularly for mastectomy. Preoperative patients underestimated the postoperative QoL for mastectomy alone (predicted: 56.8 vs actual: 83.7; P < .001). Preoperative patients underestimated QoL following mastectomy following reconstruction (predicted: 73.4 vs actual: 83.9; P < .001) and BCS (predicted: 72.2 vs actual: 88.6; P < .001). Additionally, preoperative patients overestimated stigma related to mastectomy (predicted: 3.25 vs actual: 2.43; P < .001). Finally, preoperative women overestimated stigma related to mastectomy with reconstruction (predicted: 2.54 vs actual: 2.03; P < .001) and BCS (predicted: 1.90 vs actual: 1.76; P < .001)., Conclusion: Predicting QoL and stigma following breast cancer surgery is challenging for patients facing a diagnosis for surgery. Identifying strategies to better inform patients of surgical outcomes can improve the decision-making process.

Background: Up to 60% of breast cancer patients who undergo breast-conserving surgery (BCS) require re-excision to obtain clear margins, causing delays in adjuvant treatment and poor aesthetic results. However, patient and treatment-related factors associated with re-excision are not well defined., Methods: We surveyed all women undergoing breast conserving surgery between January 2002 and May 2006 regarding their breast disease (n = 714, response rate = 79.5%). The medical record was reviewed to determine the receipt of re-excision lumpectomy following BCS, and obtain tumor stage, histology, and biopsy method (surgical versus needle biopsy). Patient age, breast size, tumor location in the breast, and receipt of chemotherapy were self-reported. Logistic regression was used to determine significant predictors of re-excision lumpectomy., Results: In this sample, 51.4% of women required only one breast excision, 41.9% required two breast excisions, and 6.6% required three breast excisions. Overall, 10.8% of women required a mastectomy following initial attempt at BCS. Factors significantly correlated with re-excision lumpectomy included smaller breast size (A cup: OR = 2.7; 95%CI: 1.32-5.52; B cup: 1.63; 95%CI: 1.02-2.62), lobular histology (OR = 1.93; 95%CI: 1.15-3.25), and receipt of surgical biopsy (OR = 3.35; 95%CI: 2.24-5.02). Women who received adjuvant chemotherapy (OR = 2.49; 95%CI: 1.19-5.22) were more likely to require re-excision compared with women who received neoadjuvant chemotherapy., Conclusions: Re-excision lumpectomy is common, and is significantly correlated with smaller breast size, lobular histology, surgical biopsy, and chemotherapy timing. Attention to these risk factors can improve the quality of care delivered to BCS patients by decreasing the cost and morbidity associated with multiple re-excision procedures.