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To address overuse of unnecessary practices, several surgical organizations have participated in the Choosing Wisely® campaign and identified four breast cancer surgical procedures as unnecessary. Despite evidence demonstrating no survival benefit for all four, evidence suggests only two have been substantially de-implemented. Our objective was to understand why surgeons stop performing certain unnecessary cancer operations but not others and how best to de-implement entrenched and emerging unnecessary procedures. We sampled surgeons who treat breast cancer in a variety of practice types and geographic regions in the United States. Using a semi-structured guide, we conducted telephone interviews (n = 18) to elicit attitudes and understand practices relating to the four identified breast cancer procedures in the Choosing Wisely® campaign. Interviews were recorded, transcribed, and anonymized. Transcripts were analyzed using inductive and deductive thematic analysis. For the two procedures successfully de-implemented, surgeons described a high level of confidence in the data supporting the recommendations. In contrast, surgeons frequently described a lack of familiarity or skepticism toward the recommendation to avoid sentinel-node biopsy in women ≥ 70 years of age and the influence of other collaborating oncology providers as justification for continued use. Regarding contralateral prophylactic mastectomy, surgeons consistently agreed with the recommendation that this was unnecessary, yet reported continued utilization due to the value placed on patient autonomy and preference. With a growing focus on the elimination of ineffective, unproven or low value practices, it is imperative that the behavioral determinants are understood and targeted with specific interventions to decrease utilization rapidly.

The aim of this study was to determine the feasibility of "hot spotting" in elective surgical populations.Prospective identification of high-cost patients, known as "hot spotting," is well developed in medical populations, but has not been performed in surgical populations. Population-based management of surgical expenditures requires identification of high-cost surgical patients to allow for effective implementation of cost-saving strategies.Using 100% Medicare claims data for 2010 to 2013, we identified patients aged 65 to 99 years undergoing elective surgical procedures. We calculated price-standardized Medicare payments for the surgical episode from the index admission through 30 days after discharge. Patient-level factors associated with payments were analyzed by multivariable linear regression.Medicare patients in the highest decile of spending accounted for a disproportionate share of aggregate costs: 30% in Colectomy (COL), 22% in coronary artery bypass grafting (CABG), 19% in Total Hip Arthroplasty, and 18% in Total Knee Arthroplasty. Medicare expenditure differences between the highest and lowest deciles were because of a 5-fold difference for COL and 3-fold difference for CABG in index hospitalization cost. In contrast, for orthopedic procedures, there were 47- to 80-fold post-acute care expenditures between highest and lowest deciles. In multivariable analyses, patients with ≥3 comorbidities had significantly higher costs than healthier patients.We found that a subset of multimorbid patients was responsible for a disproportionate share of total Medicare spending, but the individual components of spending vary by procedure. These findings suggest that targeting high-cost Medicare patients (ie, hot spotting) for cost containment efforts would be a potentially effective strategy to reduce costs in surgical populations.

Objective We sought to assess the potential changes in Medicare payments and clinical outcomes of referring high-risk surgical patients to local high-quality hospitals within small geographic areas. Summary background data Previous studies have documented a benefit in referring high-risk patients to high-quality hospitals on a national basis, suggesting selective referral as a mechanism to improve the value of surgical care. Practically, referral of patients should be done within small geographic regions; however, the benefit of local selective referral has not been studied. Methods We analyzed data on elderly Medicare beneficiaries undergoing any of 4 elective inpatient surgical procedures between 2012 and 2014. Hospitals were categorized into Metropolitan Statistical Areas by zip code and stratified into quintiles of quality based on rates of postoperative complications. Patient risk was calculated by modeling the predicted risk of a postoperative complication. Medicare payments for each surgical episode were calculated. Distances between patients' home zip code and high- and low-quality hospitals were calculated. Results One quarter of high-risk patients underwent surgery at a low-quality hospital despite the availability of a high-quality hospital in their small geographic area. Shifting these patients to a local high-quality hospital would decrease spending 12% to 37% ($2,500 for total knee and hip replacement, $6,700 for colectomy, and $11,400 for lung resection). Approximately 45% of high-risk patients treated at low-quality hospitals could travel a shorter distance to reach a high-quality hospital than the low-quality hospital they received care at. Conclusions Complication rates and Medicare payments are significantly lower for high-risk patients treated at local high-quality hospitals. This suggests triaging high-risk patients to local high-quality hospitals within small geographic areas may serve as a template for improving the value of surgical care.

Importance Through the Choosing Wisely campaign, surgical specialties identified 4 low-value breast cancer operations. Preliminary data suggest varying rates of deimplementation and have identified patient-level and clinician-level determinants of continued overuse. However, little information exists about facility-level variation or determinants of differential deimplementation. Objective To identify variation and determinants of persistent use of low-value breast cancer surgical care. Design, Setting, and Participants Retrospective cohort study in which reliability-adjusted facility rates of each procedure were calculated using random-intercept hierarchical logistic regression before and after evidence demonstrated that each procedure was unnecessary. The National Cancer Database is a prospective cancer registry of patients encompassing approximately 70% of all new cancer diagnoses from more than 1500 facilities in the United States. Data were analyzed from November 2019 to August 2020. The registry included women 18 years and older diagnosed as having breast cancer between 2004 and 2016 and meeting inclusion criteria for each Choosing Wisely recommendation. Main Outcomes and Measures Rate of each low-value breast cancer procedure based on facility type and breast cancer volume categories before and after the release of data supporting each procedure’s omission. Results The total cohort included 920 256 women with a median age of 63 years. Overall, 86% self-identified as White, 10% as Black, 3% as Asian, and 4.5% as Hispanic. Most women in this cohort were insured (51% private and 47% public), were living in a metropolitan or urban area (88% and 11%, respectively), and originated from the top half of income-earning households (65.5%). While there was significant deimplementation of axillary lymph node dissection and lumpectomy reoperation in response to guidelines supporting omission of these procedures, rates of contralateral prophylactic mastectomy and sentinel lymph node biopsy in older women increased during the study period. Academic research programs and high-volume facilities overall demonstrated the greatest reduction in use of these low-value procedures. There was significant interfacility variation for each low-value procedure. Facility-level axillary lymph node dissection rates ranged from 7% to 47%, lumpectomy reoperation rates ranged from 3% to 62%, contralateral prophylactic mastectomy rates ranged from 9% to 67%, and sentinel lymph node biopsy rates ranged from 25% to 97%. Pearson correlation coefficient for each combination of 2 of the 4 procedures was less than 0.11, suggesting that hospitals were not consistent in their deimplementation performance across all 4 procedures. Many were high outliers in one procedure but low outliers in another. Conclusions and Relevance Interfacility variation demonstrates a performance gap and an opportunity for formal deimplementation efforts targeting each procedure. Several facility-level characteristics were associated with differential deimplementation and performance.

Background To increase workforce diversity among academic medical centers, the Association of American Medical Colleges recommends multiple inclusive strategies for evaluating and hiring candidates. Our objective was to determine (1) usual and inclusive hiring practices used among academic surgery departments and (2) the barriers to utilization of inclusive hiring practices. Materials and methods We used a qualitative design and conducted semistructured interviews with academic surgery department chairs (n = 19). Participants were interviewed by phone between March 2018 and June 2018 until thematic saturation was reached. Interviews were audiotaped and transcribed verbatim. Coding for major themes was conducted independently by two investigators and discussed to consensus iteratively using thematic analysis. Results Rather than broad and publicly available postings, many chairs reported soliciting a small number of applications from trusted networks. Although chairs report making efforts to include women or underrepresented minority candidates in interview pools, these efforts are not typically formalized. Chairs often reported an inability to secure diverse applicant pools, given the narrow specialty or clinical niche for which applications were being solicited. A major emergent theme was an assessment of a “candidate's fit” for the department. For this reason, recruiting current or former trainees was considered a safe opportunity for the department, given a perception of loyalty and trust in the internal training program for surgical preparation. Conclusions Many chairs rely heavily on internal hires or trusted networks, which may limit both demographic and cognitive diversity. These findings highlight gaps between best inclusive hiring practices described in other industries and usual strategies for recruitment in US academic surgery.

BACKGROUND: There are many reasons to believe that surgeon personality traits and related leadership behaviors influence patient outcomes. For example, participation in continuing education, effective self-reflection, and openness to feedback are associated with certain personalities and may also lead to improvement in outcomes. In this context, we sought to determine if an individual surgeon’s thinking and behavior traits correlate with patient level outcomes after bariatric surgery. METHODS: Practicing surgeons from the Michigan Bariatric Surgery Collaborative (MBSC) were administered the Life Styles Inventory (LSI) assessment. The results of this assessment were then collapsed into 3 major styles that corresponded with particular patterns of an individual’s thinking and behavior: Constructive (achievement, self-actualizing, humanistic-encouraging, affiliative), Passive/Defensive (approval, conventional, dependent, avoidance), and Aggressive/Defensive (perfectionistic, competitive, power, oppositional). We compared patients level outcomes for surgeons in the lowest, middle, and highest quintiles for each style. We then used patient level risk adjusted rates of complications after bariatric surgery to quantify the impact surgeon style on post-operative outcomes. RESULTS: We found that patients undergoing bariatric surgery performed by surgeons with high levels of Constructive (achievement, self-actualizing, humanistic-encouraging, affiliative) and Passive/Defensive (approval, conventional, dependent, avoidance) styles had lower rates of adverse events compared with surgeons with low levels of the respective styles (High Constructive: 14.7% [13.8%-15.6%], Low Constructive: 17.7% [16.8%-18.6%]; High Passive: 14.8% [13.4%-16.1%], Low Passive: 18.7% [17.3%-19.9%]). Conversely, surgeons identified with high aggressive styles (perfectionistic, competitive, power, oppositional) had similar rates of postoperative adverse events compared with surgeons with low levels (High Aggressive: 15.2% [14.3%-16.1%], Low Aggressive: 14.9% [14.2%-15.6%]). CONCLUSION: Our analysis demonstrates that surgeons’ leadership styles are correlated with surgical outcomes for individual patients. This finding underscores the need for professional development for surgeons to cultivate strengths in the constructive domains including intentional self-improvement, development of interpersonal skills, and the receptiveness to feedback.

BACKGROUND Surgical resection is a cornerstone of curative-intent therapy for patients with solid organ malignancies. With increasing attention paid to the costs of surgical care, there is a new focus on variations in the costs of cancer surgery. This study evaluated the potential interactive effect of hospital quality and patient risk on expenditures for cancer resections. METHODS With 100% Medicare claim data for 2010-2013, patients aged 65 to 99 years who had undergone cancer resection were identified. Medicare payments were calculated for the surgical episode from the index admission through 30 days after discharge. Risk- and reliability-adjusted hospital rates of serious complications and mortality within 30 days of the index operation were assessed to categorize high- and low-quality hospitals. RESULTS There was no difference in patient characteristics between the highest and lowest quality hospitals. There were substantial increases in expenditures for procedures performed at the lowest quality hospitals for each procedure. Increased expenditures at the lowest quality hospitals were found for all patients, but they were highest for the highest risk patients. At low-quality hospitals, low-risk patients undergoing pancreatectomy had payments of $29,080, whereas high-risk patients had average payments of $62,687; this was a difference of $33,607 per patient episode. CONCLUSIONS Total episode expenditures for cancer resections were lower when care was delivered at low-complication, high-quality hospitals. Expenditure differences were particularly large for high-risk patients, and this suggests that the selective referral of high-risk patients to high-quality centers may be an effective strategy for optimizing value in cancer surgery. Cancer 2018;124:826-32. © 2017 American Cancer Society.

The recent national emphasis on improving value in healthcare delivery has placed increasing responsibility for health care value improvement on individual hospitals through financial incentives. Private Payer Initiatives are partnerships between providers and hospitals with payers that are intended to improve quality and value of health care. Blue Cross Blue Shield of Michigan has been a pioneer in the development and financial support of “The Michigan Model.” The Michigan Model is a is a longstanding multifaceted initiative that has successfully improved quality of healthcare delivery throughout the state through the development of collaborations between providers and acute care hospitals.

OBJECTIVE The aim of this study was to evaluate the rates of use and efficacy of stent placement for postoperative leak following bariatric surgery. SUMMARY OF BACKGROUND DATA Endoscopically placed stents can successfully treat anastomotic and staple line leaks after bariatric surgery. However, the extent to which stents are used in the management of bariatric complications and rates of reoperation remain unknown. METHODS Data from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program participant use files were analyzed for patients who experienced anastomotic or staple line leaks after bariatric surgery, and then evaluated for use of an endoscopically placed stent. Patient and procedure-level data were compared between those who underwent stent placement versus those who required reoperation. Multivariable logistic regression was used to compare outcomes between groups. RESULTS A total of 354,865 bariatric cases were captured in 2015 to 2016. One thousand one hundred thirty patients (0.3%) required intervention for a leak, of whom 275 (24%) were treated with an endoscopically placed stent. One hundred seven (39%) of the patients who received stents required reoperation as part of their care pathway. Patient characteristics were statistically similar when comparing leaks managed with stents to those treated with reoperation alone. Those treated with stents, however, had a higher likelihood of readmission (odds ratio 2.59, 95% confidence interval -1.59 to 4.20). CONCLUSION Placement of stents for management of leaks after bariatric surgery is common throughout the United States. The use of stents can be effective; however, it does not prevent reoperation and is associated with an increased likelihood of readmission. Both technique and resource utilization should be considered when choosing a management pathway for leaks.

Background Many coaching methods have been well studied and formalized, but the approach most commonly used in the continuing education of surgeons is peer coaching. Through a qualitative thematic analysis, we sought to determine if surgeons can comfortably and effectively transition to a co-learner dynamic for effective peer coaching. Methods This qualitative study evaluated 20 surgeons participating in a video review coaching exercise in October 2015. Each conversation was coded by 2 authors focusing on the dynamics of the coach and coachee relationship. Once coded, thematic analysis was performed. Results Two themes emerged in our analysis: (1) Participants often alternated between the roles of coach and coachee, even though they received assigned roles prior to the start of the session. For example, a coach would defer to the coachee, suggesting they felt unqualified to teach a particular technique or procedure. (2) The interactions demonstrated bidirectional exchange of ideas with both participants offering expertise when appropriate. For example, the coach and coachee frequently engaged in back-and-forth discussion about techniques, instrument selection, and intraoperative decision-making. Conclusion Our qualitative analysis demonstrates that surgeons naturally and effectively assume co-learner roles when participating in an early surgical coaching experience.

Background The quality of an operation depends on operative technique. There is very little evidence, however, regarding how surgeons arrive at their intraoperative decisions. The objective of this study was to determine the extent to which practicing surgeons participating in a coaching program justify their technical decisions based on their experience or based on evidence. Methods This qualitative study evaluated 10 pairs of surgeons participating in a video review coaching program in October 2015. Using thematic analysis, the conversations were coded in an iterative process with comparative analysis to identify emerging themes. Results Three major themes emerged during analysis: (1) Individuals often reported modifications in surgical technique after a negative postoperative complication; (2) participants were noted to defend the use of certain techniques or surgical decisions based on the perceived expert opinion of others; and (3) surgeons rarely referred to evidence in surgical literature as a motivation for changing surgical technique. Conclusions In this qualitative analysis of coaching conversations we found that practicing surgeons often justify their surgical decisions with anecdotal evidence and “lessons learned,” rather than deferring to surgical literature. This either represents a lack of evidence or poor uptake of existing data.