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Objective: Usage of radiation among various surgical specialists has not been comprehensively evaluated. A systems-based analysis evaluating intraoperative radiation can help identify high use factors and dose reduction behaviors leading to quality improvement initiatives.Methods: A retrospective review of all operative fluoroscopic-guided procedures from 2010 to 2017 from 4 hospitals in a tertiary academic health care system was performed.Results: One thousand two hundred fifty-two cases were analyzed, and notable trends in metrics including type of equipment, procedures, surgical field, surgical specialty, and dose reduction techniques were demonstrated. Higher radiation exposures were correlated with fixed vs. mobile C-arm usage (1229 mGy vs. 331 mGy, P = .001), abdominal/pelvic procedures (429.2 mGy vs. 274.0 mGy, P = .002), and embolization (2450.6 mGy vs. 328.2 mGy, P = .019). Vascular surgery averaged 40 times higher radiation exposure per patient than other specialties (613.3 mGy vs. 15.6 mGy, P = .001). Notably, vascular surgeons utilized dose reduction techniques less frequently than urology (21.5% vs. 70%, P = .001) but more than neurosurgery and orthopedics (21.5% vs. 1.3% and 0%, P = .001, respectively).Conclusions: A system-wide health care analysis identified vascular surgery procedures, use of a fixed C-arm, abdominal/pelvic procedures, and embolization cases as having the highest radiation exposure. These data can serve as baseline information for future quality improvement initiatives regarding fluoroscopy usage by surgeons. [ABSTRACT FROM AUTHOR]

Background: Academic productivity, as measured by number and impact of publications, is central to the career advancement and promotion of academic surgeons. We compared research productivity metrics among specialties and sought factors associated with increased productivity.Methods: Academic surgeons were identified through departmental webpages and their scholarly metrics were collected through Scopus in a standardized fashion. We collected total number of documents, h-index, and average number of publications per year in the preceding 5 years. We explored whether presence of a training program, graduate degree, academic rank and size of the clinical group affected productivity metrics. Linear regression was used for multivariable analysis.Results: We collected data on 2172 surgeons from 15 separate academic centres across Canada. Wide variability existed in metrics among specialties, with cardiac and neurosurgery being the most productive, and vascular surgery and plastic surgery being the least productive. The average number of publications was 71, and the average h-index was 18.7. The average h-index for cardiac surgery was 25.7 compared with 8.3 for vascular surgery (p < 0.001). Our multivariable model identified academic rank, surgical specialty, graduate degree, presence of a training program, and larger clinical group as being associated with increased academic productivity.Conclusion: There is variability in research productivity among Canadian surgical specialties. Cardiac surgery and neurosurgery are productive, whereas vascular surgery and plastic surgery are less productive than other surgical disciplines. Obtaining a research-oriented graduate degree, being part of a larger clinical group, and presence of a training program were all associated with higher productivity, even after adjusting for academic rank and specialty. [ABSTRACT FROM AUTHOR]

Background: To increase complex minimally invasive skills (MIS), frequent training outside the clinical setting is of uttermost importance. This study compares two low-cost pediatric MIS simulators, which can easily be used preclinically. Materials and Methods: The LaparoscopyBoxx is a portable simulator without a tracking system, with costs ranging from €90 to €315. The EoSim simulator has a built-in camera and tracking system and costs range from €780 to €1800. During several pediatric surgical conferences and workshops (January 2017-December 2018), participants were asked to use both simulators. Afterward, they completed a questionnaire regarding their opinion on realism and didactic value, scored on a five-point Likert scale. Results: A total of 50 participants (24 experts and 25 target group, one unknown) evaluated one or both simulators. Both simulators scored well on the questionnaire. The LaparoscopyBoxx scored significantly better regarding the "on screen representation of the instrument actions" (mean 4.2 versus 3.5, P = .001), "training tool for pediatric surgery" (mean 4.4 versus 3.9, P = .005), and "appealing take-home simulator" (mean 4.6 versus 4.0, P = .002). Conclusion: The simulators tested in this study were both regarded an appealing take-home simulator. The LaparoscopyBoxx scored significantly better than the EoSim, even though this is a low budget simulator without tracking capabilities. [ABSTRACT FROM AUTHOR]

Background: The Japanese endoscopic surgical skill qualification system (ESSQS) in pediatric surgery was started 10 years ago to encourage safe and appropriate pediatric minimally invasive procedures and avoid severe complications. The present study investigated the impact of the ESSQS on the incidence of serious complications in the field of pediatric endoscopic surgery. Materials and Methods: We sent a questionnaire to institutes belonging to the Japanese Pediatric Endoscopic Surgery Group. Institutes were divided into two groups: institutes with (Group A) or without (Group B) ESSQS-qualified pediatric surgeons at any point in the last 10 years. Intraoperative complications (grade 3 and 4 under the Classification of Intraoperative Complications [CLASSIC] classification), postoperative complications (grade ≥IIIb under the Clavien/Dindo classification), and the number and rate of endoscopic procedures and complications of advanced and common procedures were compared between the two groups. This study is an exempt survey since no patient identifier has been collected. Results: We collected answers from 46 of 102 institutes (response rate: 45%) (Group A: 18 institutes, Group B: 28 institutes). Intra/postoperative complications were significantly more frequent in Group A than in Group B (P = .02 and P < .001, respectively). Endoscopic operations accounted for a larger proportion of advanced and common surgeries in Group A than in Group B, and the rate of postoperative complications of advanced procedures was significantly higher in Group A than in Group B (P = .012). Conclusion: While endoscopic surgery was performed more frequently in Group A than in Group B, the incidence of intra/postoperative serious complications was significantly higher in Group A. The current Japanese ESSQS was unable to markedly reduce the rate of serious complications. [ABSTRACT FROM AUTHOR]

Introduction: In China, although burn treatment develops rapidly, and ranks in the forefront of the world, there is a relative shortage of burn specialists, which limits the development of burn education. In traditional curriculum of surgery education, burn surgery education accounts for few proportions, which results in the indifference to the burn surgery among medical students. To date, few research reported the application of Clinical pathway- Problem based Learning (CP-PBL) in burn surgery education. The objective of the study is to explore the teaching effect of this novel teaching method in burn surgery education.Methods: A pilot study was performed. One hundred and six students were randomly divided into a Lecture based Learning (LBL) only group (control group) and a LBL combined Clinical pathway- Problem based Learning group (observation group). A set of test was designed as evaluation criteria based on questions of burn surgery in National Medical Licensing Examination (NMLE) from 2011 to 2018.Results: The students with Clinical pathway- Problem based Learning had better academic performances in profession theory. Type A2 and Type A3/A4 scores in the observation group were higher than those in the control group (p < 0.05). The scores of the observation group were higher than those of control group in the domains of understanding and application (p < 0.05). They also have higher favorable impressions of learning experience.Conclusions: More active approaches yield more learning and are viewed more favorable, which provides a vital message for the evolution of curriculum in Chinese medical schools. [ABSTRACT FROM AUTHOR]

Background: Surgeons are at high risk of developing musculoskeletal disorders.Study Design: This study was designed to identify risk factors and assess intraoperative physical stressors using subjective and objective measures, including type of procedure and equipment used. Wearable sensors and pre- and postoperation surveys were analyzed.Results: Data from 116 cases (34 male and 19 female surgeons) were collected across surgical specialties. Surgeons reported increased pain in the neck, upper, and lower back both during and after operations. High-stress intraoperative postures were also revealed by the real-time measurement in the neck and back. Surgical duration also impacted physical pain and fatigue. Open procedures had more stressful physical postures than laparoscopic procedures. Loupe usage negatively impacted neck postures.Conclusions: This study highlights the fact that musculoskeletal disorders are common in surgeons and characterizes surgeons' intraoperative posture as well as surgeon pain and fatigue across specialties. Defining intraoperative ergonomic risk factors is of paramount importance to protect the well-being of the surgical workforce. [ABSTRACT FROM AUTHOR]

Objective: To compare the surgical subspecialties performing bladder exstrophy closures and characterize their practice patterns using both a national and institutional database.Methods: The National Surgical Quality Improvement Program Pediatric (NSQIPP) database was reviewed for all bladder exstrophy closures performed from 2012 to 2017. A single institutional exstrophy-epispadias complex database of 1337 patients was reviewed for patients with a bladder closure at a referring institution from 1975 to 2018. Patients with cloacal exstrophy were excluded. The subspecialties of the surgeons performing the closures were identified. Practice patterns such as the use of a pelvic osteotomy and postoperative immobilization, and perioperative outcomes were compared for each subspecialty group.Results: A total of 84 bladder exstrophy patients from NSQIPP and 263 from the author's institutional database met the inclusion criteria. From NSQIPP, 88% of closures were performed by pediatric urologists while 12% were done by other subspecialists. From the institutional database, 75% of referred bladder exstrophy closures were done by a pediatric urologist, and 25% by other services. Gender, race, operation time, length of stay, and postoperative complications were not significantly different between the groups. In one database, pediatric surgeons performed closures earlier, and in another database, pediatric urologists had greater utilization of osteotomy with different immobilization techniques. Pediatric urologists had a higher success rate.Conclusion: Pediatric urologists performed the most bladder exstrophy closures in both databases; they operated on more delayed closures with a greater use of adjunctive procedures and a higher success rate. Differences in surgical training may contribute to the differences in practice patterns. [ABSTRACT FROM AUTHOR]

Background: Smoking cessation (SC) care in the perioperative period of cardiothoracic surgery is important to reduce surgical risk and help achieve long-term smoking abstinence in patients who continue to smoke. The implementation of clinical guidelines for SC care in the perioperative period has proved challenging, yet little is known of what influences the inter-disciplinary team involved in the cardiothoracic area. This qualitative study explored the views of the clinicians involved in perioperative period of cardiothoracic surgery in Australia on their SC advice and support.Methods: Semi-structured interviews were conducted with 52 cardiothoracic surgeons, anaesthetists, nurses and physiotherapists in three public tertiary referral hospitals and three private hospitals in New South Wales (NSW). Data was thematically analysed, and categorised using the Behaviour Change Wheel "Capabilities, Opportunity, Motivation & Behaviour" (COM-B) analysis framework to understand the factors that influence clinicians' views and perceived abilities to provide SC care.Results: Barriers and facilitators to providing SC care were identified. The most commonly identified barriers in capability were the lack of knowledge, training and institutional engagement. Opportunity was hindered by lack of time, hospital support and resources, yet facilitated by the existence of a collaborative, multidisciplinary team and the ability to follow-up patients long term. In motivation, clinicians' attitudes and experience negatively influenced the initiation of the cessation conversation, while intrinsic attributes of empathy and positivity were drivers to provide SC care.Conclusions: Clinicians' views, together with inadequate SC training, resources and engagement to implement clinical guidelines, contribute to inconsistent SC care. There is a need for hospitals to provide adequate SC resources and training to all clinicians to improve SC care to cardiothoracic surgery patients throughout the perioperative period. [ABSTRACT FROM AUTHOR]

Background: Despite having considerable influence over resource allocation clinicians possess poor knowledge of healthcare costs. This study evaluated surgeons' cost-awareness with regard to surgical equipment and assessed attitudes towards health economics training using survey format.Materials and Methods: An online survey was distributed to 326 surgeons across a range of specialties in Ireland. Respondents were asked about their surgical expertise, previous training in health economics, and its role in the surgical curriculum. They were also asked to estimate the recommended retail price (RRP) of 17 commonly used items of surgical equipment. Answers within ±25% of the RRP were considered correct.Results: Of 140 respondents, 62 (44.3%) were on a surgical training scheme and 16 (11.4%) were consultants. Overall, surgeons correctly estimated the RRP of only 14.0% of items. There was no difference in accuracy between surgeons in later years of training compared to their junior counterparts (13.1 ± 8.8% versus 15.0 ± 8.8%, p = 0.115). The highest individual score was six out of 17 items correctly estimated. Participants overestimated the cost of low-cost items by 347.7% and underestimated the cost of high-cost items by 35.5%. Only 5.7% of participants had received undergraduate training in health economics but 75.0% felt it should be included in the curriculum. Over two-thirds said their practice would change if they had better knowledge of the cost of surgical equipment.Conclusion: The majority of surgeons receive little training in health economics and have poor knowledge of the cost of surgical equipment. Most would welcome more training at both an undergraduate and postgraduate level. An opportunity exists to promote cost awareness in the operating room, which could lead to a reduction in waste and improved use of resources. [ABSTRACT FROM AUTHOR]

Introduction: This study aimed to assess training of Senior House Officer-grade equivalent doctors in postgraduate surgical training or service (SHO-DIPST) in surgical specialties across the United Kingdom (UK), against nationally agreed Joint Committee on Surgical Training Quality Indicators (JCST QIs). Specific recommendations are made, with a view to improving quality of training, workforce retention and recruitment to Higher Surgical Training.Method: Prospective, observational, multicentre study conducted by the Association of Surgeons in Training, using the UK National Research Collaborative model. Any centres in the UK providing acute surgical services were eligible. SHO-DIPST with a permanent contract, on out-of-hours 'on-call rota' were included across four, one-week data capture periods (September to October 2016, February to March 2017). Adherence to five quality indicators was reported using descriptive statistics. P-values were calculated using Student's t-test for continuous data, with a 5% level of significance.Results: 2569 SHO-DIPST were included from all ten surgical specialties in 141 NHS trusts across all 16 Local Education and Training Boards in the UK. 960 SHO-DIPST were in registered 'training' posts (37.3%). The median number of SHO-DIPST per rota was 7.0 (IQR 5.0-9.0). Adherence to the five included JCST QIs ranged from 6.0 to 53.1%. Only four SHO-DIPST posts across the study population met all five JCST QIs (0.3%). The total number of training sessions was higher for those in registered training posts (p < 0.001), with significant specialty and regional variation.Conclusions: Only four early years postgraduate surgical training posts in the UK meet nationally approved minimum quality standards. Specific recommendations are made to improve training in this cohort and to bolster recruitment and retention into Higher Surgical Training. [ABSTRACT FROM AUTHOR]

Background: The responsibility for ensuring that studies are adequately reported is primarily that of those conducting the study; however, journal policies may influence how thoroughly authors choose to report their research. The use of reporting guidelines and prospective trial registration are promising avenues for ensuring that published studies adhere to the highest methodological standards. The purpose of this study is to evaluate orthopaedic surgery journal policies regarding reporting guidelines and trial registration, and to evaluate the effects that these policies have on adherence to reporting.Methods: We conducted a cross-sectional survey of journal policies and "Instructions for Authors" to determine the journals' policies and guidance regarding use of reporting guidelines and study registration. We also examined whether trials published in journals referencing CONSORT (Consolidated Standards of Reporting Trials) had higher rates of compliance with publishing a CONSORT flow diagram and whether journals with trial registration policies were more likely to contain registered trials than journals without these requirements.Results: Of the 21 orthopaedic surgery journals, 6 (29%) did not mention a single guideline, and clinical trial registration was required by 11 (52%) orthopaedic surgery journals and recommended by 2 (10%). Of the 21 general medical journals, 3 (14%) did not mention a single guideline, and trial registration was required by 13 (62%) general medical journals and recommended by 5 (24%) others. Furthermore, journals that referenced CONSORT were more likely to publish trials with a CONSORT flow diagram. Journals with trial registration policies were more likely to publish registered trials.Conclusions: Reporting guidelines and trial registration are suboptimally required or recommended by orthopaedic surgery journals. These 2 mechanisms may improve methodology and quality, and should be considered for adoption by journal editors in orthopaedic surgery.Clinical Relevance: Because orthopaedic surgeons rely on high-quality research to direct patient care, measures must be taken to ensure that published research is of the highest quality. The use of reporting guidelines and prospective clinical trial registration may improve the quality of orthopaedic research, thereby improving patient care. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the Urological resident's attitude and experience with surgical simulation in residency education using a multi-institutional, multi-modality model.Materials and Methods: Residents from 6 area urology training programs rotated through simulation stations in 4 consecutive sessions from 2014 to 2017. Workshops included GreenLight photovaporization of the prostate, ureteroscopic stone extraction, laparoscopic peg transfer, 3-dimensional laparoscopy rope pass, transobturator sling placement, intravesical injection, high definition video system trainer, vasectomy, and Urolift. Faculty members provided teaching assistance, objective scoring, and verbal feedback. Participants completed a nonvalidated questionnaire evaluating utility of the workshop and soliciting suggestions for improvement.Results: Sixty-three of 75 participants (84%) (postgraduate years 1-6) completed the exit questionnaire. Median rating of exercise usefulness on a scale of 1-10 ranged from 7.5 to 9. On a scale of 0-10, cumulative median scores of the course remained high over 4 years: time limit per station (9; interquartile range [IQR] 2), faculty instruction (9, IQR 2), ease of use (9, IQR 2), face validity (8, IQR 3), and overall course (9, IQR 2). On multivariate analysis, there was no difference in rating of domains between postgraduate years. Sixty-seven percent (42/63) believe that simulation training should be a requirement of Urology residency. Ninety-seven percent (63/65) viewed the laboratory as beneficial to their education.Conclusion: This workshop model is a valuable training experience for residents. Most participants believe that surgical simulation is beneficial and should be a requirement for Urology residency. High ratings of usefulness for each exercise demonstrated excellent face validity provided by the course. [ABSTRACT FROM AUTHOR]

Objective: Surgery is one of the riskiest and most important medical acts that is performed today. Understanding the ways in which surgeries are similar or different from each other is of major interest to understand and analyze surgical behaviors. This article addresses the issue of identifying discriminative patterns of surgical practice from recordings of surgeries. These recordings are sequences of low-level surgical activities representing the actions performed by surgeons during surgeries.Materials and Method: To discover patterns that are specific to a group of surgeries, we use the vector space model (VSM) which is originally an algebraic model for representing text documents. We split long sequences of surgical activities into subsequences of consecutive activities. We then compute the relative frequencies of these subsequences using the tf*idf framework and we use the Cosine similarity to classify the sequences. This process makes it possible to discover which patterns discriminate one set of surgeries recordings from another set.Results: Experiments were performed on 40 neurosurgeries of anterior cervical discectomy (ACD). The results demonstrate that our method accurately identifies patterns that can discriminate between (1) locations where the surgery took place, (2) levels of expertise of surgeons (i.e., expert vs. intermediate) and even (3) individual surgeons who performed the intervention. We also show how the tf*idf weight vector can be used to both visualize the most interesting patterns and to highlight the parts of a given surgery that are the most interesting.Conclusions: Identifying patterns that discriminate groups of surgeon is a very important step in improving the understanding of surgical processes. The proposed method finds discriminative and interpretable patterns in sequences of surgical activities. Our approach provides intuitive results, as it identifies automatically the set of patterns explaining the differences between the groups. [ABSTRACT FROM AUTHOR]

Background: An intraoperative adverse event (iAE) is often directly attributable to the surgeon's technical error and/or suboptimal intraoperative judgment. We aimed to examine the psychological impact of iAEs on surgeons as well as the surgeons' attitude about iAE reporting.Study Design: We conducted a web-based cross-sectional survey of all surgeons at 3 major teaching hospitals of the same university. The 29-item questionnaire was developed using a systematic closed and open approach focused on assessing the surgeons' personal account of iAE incidence, emotional response to iAEs, available support systems, and perspective about the barriers to iAE reporting.Results: The response rate was 44.8% (n = 126). Mean age of respondents was 49 years, 77% were male, and 83% performed >150 procedures/year. During the last year, 32% recalled 1 iAE, 39% recalled 2 to 5 iAEs, and 9% recalled >6 iAEs. The emotional toll of iAEs was significant, with 84% of respondents reporting a combination of anxiety (66%), guilt (60%), sadness (52%), shame/embarrassment (42%), and anger (29%). Colleagues constituted the most helpful support system (42%) rather than friends or family; a few surgeons needed psychological therapy/counseling. As for reporting, 26% preferred not to see their individual iAE rates, and 38% wanted it reported in comparison with their aggregate colleagues' rate. The most common barriers to reporting iAEs were fear of litigation (50%), lack of a standardized reporting system (49%), and absence of a clear iAE definition (48%).Conclusions: Intraoperative AEs occur often, have a significant negative impact on surgeons' well-being, and barriers to transparency are fear of litigation and absence of a well-defined reporting system. Efforts should be made to support surgeons and standardize reporting when iAEs occur. [ABSTRACT FROM AUTHOR]

Background: With increasing active shooter and intentional mass casualty events, as well as everyday injuries resulting in severe bleeding, there have been calls for the public to learn bleeding control techniques. The aims of this project were to offer bleeding control training to surgeons attending the Clinical Congress of the American College of Surgeons (ACS), to determine if the trained surgeons believe that teaching bleeding control to the public should be a priority of the ACS, and to assess the surgeon trainees' perceptions regarding the appropriateness of the course for a public audience.Study Design: This was an educational program with a post-course evaluation to determine if the bleeding control course is appropriate for a public audience.Results: Three hundred forty-one surgeons were trained. All were trained and successfully performed a return demonstration. Regarding perceptions of the participating surgeons that teaching bleeding control to the public should be a priority of the ACS, 93.79% of the 322 surgeons responding indicated agreement with this proposition. Regarding whether or not the training was at an appropriate level of difficulty for the public, 93.13% of the 320 respondents to this item agreed that it was appropriate.Conclusions: The surgeons who were trained were very much in favor of making training the public a priority of the ACS. With additional training of surgeons and other health care professionals as trainers, and the engagement of the public, the goal of having a citizenry prepared to stop bleeding can be achieved. [ABSTRACT FROM AUTHOR]

Background: Concerns persist about the effect of current duty hour reforms on resident educational outcomes. We investigated whether a flexible, less-restrictive duty hour policy (Flexible Policy) was associated with differential general surgery examination performance compared with current ACGME duty hour policy (Standard Policy).Study Design: We obtained examination scores on the American Board of Surgery In-Training Examination, Qualifying Examination (written boards), and Certifying Examination (oral boards) for residents in 117 general surgery residency programs that participated in the Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) Trial. Using bivariate analyses and regression models, we compared resident examination performance across study arms (Flexible Policy vs Standard Policy) for 2015 and 2016, and 1 year of the Qualifying Examination and Certifying Examination. Adjusted analyses accounted for program-level factors, including the stratification variable for randomization.Results: In 2016, FIRST trial participants were 4,363 general surgery residents. Mean American Board of Surgery In-Training Examination scores for residents were not significantly different between study groups (Flexible Policy vs Standard Policy) overall (Flexible Policy: mean [SD] 502.6 [100.9] vs Standard Policy: 502.7 [98.6]; p = 0.98) or for any individual postgraduate year level. There was no difference in pass rates between study arms for either the Qualifying Examination (Flexible Policy: 90.4% vs Standard Policy: 90.5%; p = 0.99) or Certifying Examination (Flexible Policy: 86.3% vs Standard Policy: 88.6%; p = 0.24). Results from adjusted analyses were consistent with these findings.Conclusions: Flexible, less-restrictive duty hour policies were not associated with differences in general surgery resident performance on examinations during the FIRST Trial. However, more years under flexible duty hour policies might be needed to observe an effect. [ABSTRACT FROM AUTHOR]

Background: The advent of three-dimensional passive stereoscopic imaging has led to the development of 3D laparoscopy. In simulation tasks, a reduction in error rate and performance time is seen with 3D compared to two-dimensional (2D) laparoscopy with both novice and expert surgeons. Robotics utilises 3D and instrument articulation through a console interface. Robotic trials have demonstrated that tasks performed in 3D produced fewer errors and quicker performance times compared with those in 2D. It was therefore perceived that the main advantage of robotic surgery was in fact 3D. Our aim was to compare 3D straight-stick laparoscopic task performance (3D) with robotic 3D (Robot), to determine whether robotic surgery confers additional benefit over and above 3D visualisation.Methods: We randomised 20 novice surgeons to perform four validated surgical tasks, either with straight-stick 3D laparoscopy followed by 3D robotic surgery or in the reverse order. The trial was conducted in two fully functional operating theatres. The primary outcome of the study was the error rate as defined for each task, and the secondary outcome was the time taken to complete each task. The participants were asked to perform the tasks as quickly and as accurately as possible. Data were analysed using SPSS version 21.Results: The median error rate for completion of all four tasks with the robot was 2.75 and 5.25 for 3D with a P value <0.001. The median performance time for completion of all four tasks with the robot was 157.1 and 342.5 s for 3D with a P value <0.001.Conclusions: Our study has shown that for novice surgeons, there is a significant benefit in a simulated setting of 3D robotic systems over 3D straight-stick laparoscopy, in terms of reduced error rate and quicker task performance time. [ABSTRACT FROM AUTHOR]

Background: There is an increased desire among patients and families to be involved in the surgical decision-making process. A surgeon's ability to provide patients and families with patient-specific estimates of postoperative complications is critical for shared decision making and informed consent. Surgeons can also use patient-specific risk estimates to decide whether or not to operate and what options to offer patients. Our objective was to develop and evaluate a publicly available risk estimation tool that would cover many common pediatric surgical procedures across all specialties.Study Design: American College of Surgeons NSQIP Pediatric standardized data from 67 hospitals were used to develop a risk estimation tool. Surgeons enter 18 preoperative variables (demographics, comorbidities, procedure) that are used in a logistic regression model to predict 9 postoperative outcomes. A surgeon adjustment score is also incorporated to adjust for any additional risk not accounted for in the 18 risk factors.Results: A pediatric surgical risk calculator was developed based on 181,353 cases covering 382 CPT codes across all specialties. It had excellent discrimination for mortality (c-statistic = 0.98), morbidity (c-statistic = 0.81), and 7 additional complications (c-statistic > 0.77). The Hosmer-Lemeshow statistic and graphic representations also showed excellent calibration.Conclusions: The ACS NSQIP Pediatric Surgical Risk Calculator was developed using standardized and audited multi-institutional data from the ACS NSQIP Pediatric, and it provides empirically derived, patient-specific postoperative risks. It can be used as a tool in the shared decision-making process by providing clinicians, families, and patients with useful information for many of the most common operations performed on pediatric patients in the US. [ABSTRACT FROM AUTHOR]

With changes in work hour limitations, there is an increasing need for objective determination of technical proficiency. Electromagnetic hand-motion analysis has previously shown only time to completion and number of movements to correlation with expertise. The present study was undertaken to evaluate the efficacy of hand-motion-tracking analysis in determining surgical skill proficiency. A nine-degree-of-freedom sensor was used and mounted on the superior aspect of a needle driver. A one-way analysis of variance and Welch's t test were performed to evaluate significance between subjects. Four Novices, four Trainees, and three Experts performed a large vessel patch anastomosis on a phantom tissue. Path length, total number of movements, absolute velocity, and total time were analyzed between groups. Compared to the Novices, Expert subjects exhibited significantly decreased total number of movements, decreased instrument path length, and decreased total time to complete tasks. There were no significant differences found in absolute velocity between groups. In this pilot study, we have identified significant differences in patterns of motion between Novice and Expert subjects. These data warrant further analysis for its predictive value in larger cohorts at different levels of training and may be a useful tool in competence-based training paradigms in the future. [ABSTRACT FROM AUTHOR]

Background: The fundamentals of endoscopic surgery (FES) examination measures the knowledge and skills required to perform safe flexible endoscopy. A potential limitation of the FES skills test is the size and cost of the simulator on which it was developed (GI Mentor II virtual reality endoscopy simulator; Simbionix LTD, Israel). A more compact and lower-cost alternative (GI Mentor Express) was developed to address this issue. The purpose of this study was to obtain evidence for the validity of scores obtained on the Express platform, so that it can be used for testing.Study Design: General surgery residents at various levels of training and practicing endoscopists at five institutions participated. Each completed the five FES tasks on both simulator platforms in random order, with 3-14 days between tests. Scores were calculated using the same standardized computer-generated algorithm and compared using Pearson's correlation coefficient.Results: There were 58 participants (mean age 32; 76% male) with a broad range of endoscopic experience. The mean (95% confidence interval) FES scores were 72 (67:77) on the GI Mentor II and 66 (60:71) on the Express. The correlation between scores on the two platforms was 0.86 (0.77:0.91; p < 0.0001).Conclusion: There is a high correlation between FES manual skills scores measured on the original platform and the new Express, providing evidence to support the use of the GI Mentor Express for FES testing. [ABSTRACT FROM AUTHOR]

Background: Surgical residency training aims to prepare the surgical resident to become an independent practitioner of surgery. Because surgical residency training remains the sole educational channel to prepare surgeons for independent practice, our study aimed to explore the effect of resident involvement in surgery across a broad spectrum of surgical specialties to answer questions patients, surgeons, and surgical residency program directors may have concerning the effect of having residents participate in performing surgical operations.Study Design: This analysis used the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database to establish whether patients having operations involving residents were at a risk of postoperative mortality or morbidity similar to patients having operations performed by attending surgeons alone, across a wide array of surgical procedures.Results: For operations in which residents were involved, the adjusted odds ratio (OR) for mortality was 0.93 (95% CI 0.90 to 0.97), as compared with the group of patients on whom attending surgeons operated alone without any level of resident involvement. For operations in which residents were involved, the adjusted OR for morbidity was 1.02 (95% CI 1.00 to 1.04), as compared with the group of patients on whom attending surgeons operated alone without any level of resident involvement. There was a slightly statistically significantly higher risk of cardiac and respiratory morbidities in the group with any level of resident involvement as compared with the "attending alone" group.Conclusions: Our study confirms that, across different surgical subspecialties, resident involvement in surgery is associated with comparable morbidity and lower mortality outcomes. This provides a reassuring answer to patients, attending surgeons, and surgical program directors. [ABSTRACT FROM AUTHOR]

Objectives: The intensivist-led model of ICU care requires surgical consultants and the ICU team to collaborate in the care of ICU patients and to communicate effectively across teams. We sought to characterize communication between intensivists and surgeons and to assess enablers and barriers of effective communication.Design: Qualitative interview study. An inductive data analysis approach was taken.Setting: Seven intensivist-led ICUs in four academic hospitals.Subjects: Surgeons (attendings and residents), intensivists (attendings and residents), and ICU nurses participating in the care of surgical patients in the ICU.Interventions: None.Measurements and Main Results: Communication enablers and barriers existed at two distinct levels: 1) organizational and 2) cultural. At an organizational level, participants identified that formally sanctioned communication structures and processes often acted as barriers to communication. Participants had developed informal strategies to improve communication. At a cultural level, surgical and ICU participants often expressed conflicting perspectives regarding patient ownership, scope of practice, and clinical expertise.Conclusions: Major barriers to optimal communication between surgical and ICU teams exist in the intensivist-led ICU environment. Many are related to the structures and processes meant to facilitate communication across teams and others to how some aspects of care in the ICU are conceptualized. Multiple actionable opportunities exist to improve communication in the intensivist-led ICU. [ABSTRACT FROM AUTHOR]

Introduction: Applicants in the NRMP for pediatric surgery have little objective data available regarding factors predicting successful matching. We analyzed data from applicants at our institution to attempt to identify parameters correlated with three outcomes: successfully matching, or attaining either a top ten or top three ranking in our final submitted match list.Methods: After IRB approval, we reviewed ERAS documents for all applicants (n = 146) over 3 years (candidates for the 2007, 2008, and 2009 fellowship years). An interview was offered to 75% of the applicants (Table 1). We analyzed over 20 factors; including demographics, number of publications and first author publications, number of book chapters, national presentations, prior match attempts, advanced degrees, quality of recommendation letters, and ABSITE scores. Significant variables were evaluated with multiple logistic regression analysis to identify independent predictors.Results: Variables correlated with successful outcome for each of the three endpoints are shown in Table 2. The number of peer-reviewed publications and first author publications, and AOA membership were highly correlated with a favorable outcome for all three endpoints. High ABSITE scores were significantly correlated with top ten rank. Research experience and outstanding letters of recommendation were significantly associated with a top ten ranking and overall match success. Variables associated only with overall match success included number of book chapters, graduation from a US medical school, quality of recommendation letters, and being granted an interview at our institution. Logistic regression analysis demonstrated no independent factors for overall match success; number of publications was significant for both top ten and top three ranking (P = 0.006 for each); number of first author publications (P = 0.002) and AOA membership (P = 0.03) were independent predictors for top three ranking.Conclusions: Applicant variables associated with success in the match included quality of letters, number and type of publications, research experience, graduation from a US medical school, and AOA membership. Factors not correlated with outcome included advanced degrees (PhD, Masters), other fellowship training, and community-based versus university-based residency training. Logistic regression analysis demonstrated no independent factors for overall match success. [ABSTRACT FROM AUTHOR]

Tissue engineering and regenerative medicine research is being aggressively pursued in attempts to develop biological substitutes to replace lost tissue or organs. Remarkable degrees of success have been achieved in the generation of a variety of tissues and organs as a result of concerted contributions by multidisciplinary groups in the field of biotechnology. Engineering of an organ is a complex process which is initiated by appropriate sourcing of cells and their controlled proliferation to achieve critical numbers for seeding on biodegradable scaffolds in order to create cell-scaffold constructs, which are thereafter maintained in bioreactors to generate tissues identical to those required for replacement. Extensive efforts in understanding the characteristics of cells and their interaction with specifically tailored scaffolds holds the key to their attachment, controlled proliferation and differentiation, intercommunication, and organization to form tissues. The demand for tissue-engineered organs is enormous and this technology holds the promise to supply customized organs to overcome the severe shortages that are currently faced by the pediatric patient, especially due to organ-size mismatch. The contemporary state of tissue-engineering technology presented in this review summarizes the advances in the various areas of regenerative medicine and addresses issues that are associated with its future implementation in the pediatric surgical patient. [ABSTRACT FROM AUTHOR]

Background: Surgical crises represent unrecognized opportunities for improving patient safety and adding value in healthcare. The first step in a crisis response is to contain and mitigate harm. While the principles of damage control are well established in surgery, methods of containing harm on broader clinical and organizational levels are not clearly defined.Study Design: A multimethods qualitative study identified crisis containment strategies and tools in commercial aviation. These were translated and clinically adapted in 3 stages: semi-structured observational fieldwork with commercial airlines, interviews with senior pilots, and focus groups with both healthcare and aviation safety experts. Thematic analysis and expert consensus methods were used to derive a framework for crisis containment.Results: Fieldwork with 2 commercial airlines identified 2 crisis containment concepts: the detrimental impact of surprising or startling events on operator performance; and the use of prioritization tools to take basic but critical actions (Aviate, Navigate and Communicate model). Twenty-two experts in aviation and healthcare practice informed the topic of crisis containment in 17 interviews and 3 focus groups. Three strategies were identified and used to form a crisis containment algorithm: 1. Manage the operators' startle response to facilitate meaningful mitigating actions (STOP tool); 2. Take priority actions to secure core functions. These included managing patients' physiologic shock, optimizing environmental risks, and mobilizing resources (Perfuse, Move and Communicate tool); 3. Deploy well-rehearsed drills targeting case-specific harms or errors (Memory Actions). This model requires validation in clinical practice.Conclusions: Crisis containment can be achieved by controlling operators' startle response, applying prioritization tools, and deploying drills against specific failures. The application of this model may extend to healthcare areas outside surgery. [ABSTRACT FROM AUTHOR]

Introduction: Surgeon specialization has been shown to result in improved outcomes but may not be the sole measure of surgical quality in hepato-pancreatico-biliary (HPB) surgery. We attempted to determine which factors predominate in optimal patient outcomes between volume, surgeon, and hospital resources.Methods: All non-transplant pancreatic (n = 7195) and liver operations (n = 4809) from the Nationwide Inpatient Sample (NIS) were examined from 1998-2005. Surgeons and hospitals were divided into two groups, transplant (TX) or non-transplant (non-TX), using the unique surgeon and hospital identifier of NIS. A logistic regression model examined the relationship between factors while accounting for patient and hospital factors.Results: We identified 4,355 primary surgeons (165 TX, 4,190 non-TX) who performed HPB surgery in 675 hospitals across 12 different states. Non-TX surgeons performed the majority of pancreatic (97%) and liver procedures (81%). There was no difference in mortality after HPB surgery depending on surgeon specialty (p = 0.59). Factors for inpatient death after HPB surgery included increasing age, male gender, and public insurance (p < 0.05). In addition, surgery performed at a TX center had a 21% lower odds of perioperative mortality.Discussion: Non-TX surgeons performed the majority of pancreatic and liver surgery in the US. Hospital factors like support of transplantation but not surgical specialty, appeared to impact operative mortality. Future regulatory benchmarks should consider these types of center-based facilities and resources to assess patient outcomes. [ABSTRACT FROM AUTHOR]

Background: The Accreditation Council for Graduate Medical Education resident work hour limitations were implemented in July, 2003. Effects on faculty are not well understood.Objective: The objective of this study was to determine the effects of the resident work hour limitations on the professional lives of faculty physicians.Design and Participants: Survey of faculty physicians at three teaching hospitals associated with university-based internal medicine and surgery residency programs in Seattle, Washington. Physicians who attended on Internal Medicine and Surgery in-patient services during the 10 mo after implementation of work hour limitations were eligible for participation (N = 366); 282 physicians (77%) returned surveys.Measurements: Participants were asked about the effects of resident work hour limitations on aspects of their professional lives, including clinical work, research, teaching, and professional satisfaction.Results: Most attending physicians reported that, because of work hour limitations, they spent more time on clinical work (52%), felt more responsibility for supervising patient care (65%), and spent less time on research or other academic pursuits (51%) and teaching residents (72%). Reported changes in work content were independently associated with the self-reported probability of leaving academic medicine in the next 3 y.Conclusions: Resident work hour limitations have had large effects on the professional lives of faculty. These findings may have important implications for recruiting and retaining faculty at academic medical centers. [ABSTRACT FROM AUTHOR]

Discusses the metamorphosis of vascular surgeons to endovascular specialists and looks whether vascular surgery should have an independent board. Changes that have occurred in vascular disease treatment during "Endovascular Revolution"; Significance of an independent American Board of Vascular Surgery (ABVS); Action taken by the ABVS with the Society of Clinical Vascular Surgery in response to the Primary Certificate that aims to shut down the ABVS forever.

Inpatient and outpatient data were used to create market segments consisting of hierarchical combinations of surgical procedure, then type of payer, and then location of patients' residences. The competitive effect of one hospital's caseload for a given surgical specialty on the caseload of another hospital was determined from the numbers of patients in each segment. Earlier methods for estimating surgical competition that ignored market segments over-estimated the competitive effects of one hospital on another. Thus, results differed from those obtained previously for all types of hospital admissions. When actual market segments with homogeneous groups of patients are used, competitive effects of hospitals in the same market area are far less than expected. [ABSTRACT FROM AUTHOR]

Background: We wanted to determine the importance of factors in primary care physicians' choice of specialist when referring patients and to compare importance ratings by physicians' race and sex.Methods: Using a cross-sectional study design, we surveyed a stratified national sample of 1,252 primary care physicians serving adults to include equal numbers of black women, white women, black men, and white men. We assessed the percentage of physicians rating each of 17 items to be of major importance in choosing a specialist and compared importance ratings by physicians' race and sex.Results: The response rate was 59.1%. Medical skill, appointment timeliness, insurance coverage, previous experience with the specialist, quality of specialist communication, specialist efforts to return patient to primary physician for care, and the likelihood of good patient-specialist rapport were of major importance to most respondents. Compared with black physicians, white physicians were more likely to rate previous experience with the specialist (65% vs 55%, P = .05) and board certification (41% vs 29%, P < .05) to be of major importance. White physicians were somewhat less likely than black physicians (17% vs 26%, P = .06) to rate patient convenience to be of major importance. Compared with male physicians, female physicians were more likely to rate the patient's insurance status to be of major importance (60% vs 44%, P < .01).Conclusions: Primary care physicians serving adults consider several factors to be of major importance when choosing a specialist. The importance of patient convenience, previous experience with the specialist, specialist board certification, and insurance coverage accepted by specialist varied by physicians' race and sex. A better understanding of factors important to a diverse physician workforce may help to improve the referral process. [ABSTRACT FROM AUTHOR]

Background: Since 1991 the authors have offered a course that identifies content deficits, but only provides instruction directed at improving verbal and nonverbal behaviors. We report the outcome of this 10-year effort as success on the certifying examination of the American Board of Surgery between 1991 and 2001.Methods: Sixteen 5-day courses were scheduled over 10 years. Participants included those who had not taken the oral examination or had failed at least once and invited senior faculty (n = 26). Sites were chosen to replicate the actual examination setting.Results: There were 122 participants, with follow-up data available on 88. Success in the certifying examination after completing the course is 96 percent.Conclusions: Evaluation of communication deficits and training to improve them is strongly associated with success. Clearly, this course is effective at identifying communication behaviors that are interfering with success on the certifying examination of the American Board of Surgery. [ABSTRACT FROM AUTHOR]

Background: Increasingly, surgeons are adopting broader roles in emergency response, on both clinical and executive levels. These have highlighted the need to develop healthcare-specific crisis management systems. Cross-professional research between safety-critical industries is a valuable method for learning crisis control. Commercial aviation, in particular, has been used to drive innovation in surgical safety. This study aimed to identify, adapt, and operationalize a surgical crisis management framework based on current practice in commercial aviation.Study Design: A multimethod qualitative study interrogated safety experts in commercial aviation and healthcare. Stage I used immersive observational fieldwork in commercial aviation practice. Stage II performed semi-structured interviews with senior airline pilots. "Snowball" sampling targeted professional networks, recruiting 17 pilots from 4 airlines. Thematic analysis was used to derive a model of crisis management. Stage III undertook 3 focus groups with 5 pilots and 5 healthcare safety specialists. Expert consensus methods were used to adapt the model to clinical practice.Results: Interview data provided 2,698 verbatim quotes on crisis management from aviation experts with a combined flying experience of 188,000 hours. Aviation crisis management was structured in 3 phases: avoid, trap, and mitigate. Adapted to clinical practice, these translated to crisis preparedness, recovery, and containment interventions. Additionally, the study identified 7 types of implementation tools and 9 crisis management skills that could be used to operationalize this framework in surgical practice.Conclusions: Surgical crisis management can follow the avoid, trap, and mitigate framework used in commercial aviation. Implementation relies on the combined use of crisis skills and performance tools. Crisis management should be delivered as part of a systems-based approach that relies on well-integrated failure management models. Simulation and in-situ validation of this framework is needed. [ABSTRACT FROM AUTHOR]

Background: If Asian American and Pacific Islanders (AAPIs) are not recognized within patients in health services research, we miss an opportunity to ensure health equity in patient outcomes. However, it is unknown what the rates are of AAPIs inclusion in surgical outcomes research.Study Design: Through a scoping review, we used Covidence to search MEDLINE, EMBASE, PsycINFO, Web of Science, Scopus, and CINAHL for studies published in 2008-2018 using NSQIP data. NSQIP was chosen because of its national scope, widespread use in research, and coding inclusive of AAPI patients. We examined the proportion of studies representing AAPI patients in the demographic characteristics and Methods, Results, or Discussion section. We then performed multivariable logistic regression to examine associations between study characteristics and AAPI inclusion.Results: In 1,264 studies included for review, 62% included race. Overall, only 22% (n = 278) of studies included AAPI patients. Of studies that included race, 35% represented AAPI patients in some component of the study. We found no association between sample size or publication year and inclusion. Studies were significantly more likely to represent AAPI patients when there was a higher AAPI population in the region of the first author's institution (lowest vs highest tercile; p < 0.001). Studies with a focus on disparities were more likely to include AAPI patients (p = 0.001).Conclusions: Our study is the first to examine AAPI representation in surgical outcomes research. We found < 75% of studies examine race, despite availability within NSQIP. Little more than one-third of studies including race reported on AAPI patients as a separate group. To provide the best care, we must include AAPI patients in our research. [ABSTRACT FROM AUTHOR]

Background: Complex lower urinary tract injury resulting from hysterectomy is a rare but highly morbid complication. Although intraoperative recognition reduces the risk of serious sequelae, observational studies have shown that most complex lower urinary tract injuries are recognized in the postoperative period. To date, limited research exists describing the timing of diagnosis of complex lower urinary tract injury or risk factors associated with complex lower urinary tract injury diagnosed in the postoperative period.Objective: This analysis aimed to describe the time to diagnosis of complex lower urinary tract injury among women undergoing benign hysterectomy. We also aimed to identify the intraoperative risk factors for differences in type and timing of complex lower urinary tract injury in the 30-day postoperative period using a large prospective national surgical database.Study Design: This was a retrospective analysis using the National Surgical Quality Improvement Program hysterectomy data set from 2014 to 2018. All benign hysterectomies were included. Sociodemographic factors, health status, surgeon type, and other operative characteristics were extracted. A complex lower urinary tract injury was defined as at least 1 ureteral obstruction, ureteral fistula, or bladder fistula diagnosed within the first 30 days following surgery. Bivariate and multivariate logistic regression and cox proportional hazards assessed differences in odds of and time until diagnosis of complex lower urinary tract injury. Proportional hazard assumptions were evaluated with martingale residuals and supremum tests. Significance thresholds were 0.05 for all analyses.Results: In this study, 100,823 women met the inclusion criteria. Median time to diagnosis of complex lower urinary tract injury was 10 days (interquartile range, 3-19) and varied significantly based on type of injury (P<.01) with ureteral obstruction (6; interquartile range, 2-16) recognized earlier than ureteral fistula (12; interquartile range, 7-21) and bladder fistula (14; interquartile range, 4-23). In addition, 8.65% of complex lower urinary tract injury were diagnosed on the day of surgery. Total laparoscopic hysterectomy had the lowest rate of complex lower urinary tract injury in unadjusted and adjusted analysis, with abdominal hysterectomy (adjusted odds ratio, 2.02; 95% confidence interval, 1.21-3.36) and vaginal hysterectomy (adjusted odds ratio, 2.05; 95% confidence interval, 1.16-3.62) having greater odds of ureteral obstruction, whereas laparoscopic assisted vaginal hysterectomy had the greatest odds of fistula (adjusted odds ratio, 2.10; 95% confidence interval, 1.26-3.48). Concomitant apical suspension was associated with a 6-day reduction in median time to diagnosis (P=.01), and surgery with a gynecologic oncologist was associated with a 9.5-day increase in median time to diagnosis (P=.01). Cox proportional hazards analysis confirmed these findings when controlling for confounders.Conclusion: Greater than 91% of complex lower urinary tract injury diagnoses in the National Surgical Quality Improvement Program hysterectomy database were diagnosed after the day of surgery. Route of hysterectomy, concomitant apical suspension, and primary surgeon specialty are associated with differences in both type of injury and time until diagnosis. These intraoperative risk factors should be considered when assessing for complex lower urinary tract injury in the 30-day postoperative period. [ABSTRACT FROM AUTHOR]

This paper estimates a model of physician labor supply, focusing on the impacts of wage and non-wage income. We find evidence of significant income effects. For male physicians, the income effect of a wage change on labor supply is negative, with an elasticity of -0.26. The pure substitution effect of a wage change increases labor supply: a 1% increase in wages leads to a 0.49% increase in labor supply, controlling for income effects. The results also suggest that the labor supply decisions of females are more responsive to variations in their earnings than are those of males. [ABSTRACT FROM AUTHOR]

Unlabelled: BACKGROUND--There is a general perception that procedural medical services are reimbursed at an inappropriately greater rate than cognitive services. By congressional mandate, the Health Care Financing Administration (HCFA) has been directed to establish a Medicare fee schedule to shift funding under a budget-neutral assumption from procedural to cognitive services. To provide a rational basis for this change, Hsiao et al (Harvard-Hsiao) developed a resource-based relative value scale (RBRVS) that equates the value of a service to the resources necessary to generate the service. METHODS--Instead of focusing on relative values and fee schedules ("price-per-unit-service"), the present study employs the standard commercial/industrial method of determining reimbursement rate (income divided by hours of labor) for 15 medical and surgical specialties. Data from independent sources are used to determine income and hours of professional effort for each of the specialties studied. Harvard-Hsiao and HCFA predicted the percent change in income for each of the specialties under the initial RBRVS and the HCFA fee schedule. The predicted income was then employed in this study to recompute reimbursement rates under the newly proposed payment systems.Results: CURRENT PAYMENT SYSTEM--Average annual incomes for medical and surgical specialties are $124,500 and $176,600, respectively, a 42% difference (P = .03). Average weekly work hours (nominal hours, as adjusted for overtime) for medical and surgical specialties are 70.6 and 87.8, respectively (P = .005). Average hourly reimbursement rates for medical ($33.90) and surgical ($38.80) specialties are not substantially different (P, not significant). The difference in annual income is explained by the 17.2 hours per week of additional work hours by surgeons. The erroneous perception that procedurists are reimbursed at a higher rate than cognitive practitioners likely arises from differences in billing methods by which surgeons shift charges for cognitive work hours to the 18% of their time spent in the operating room.Results: PROPOSED RBRVS AND HCFA PAYMENT SYSTEM--The income of all specialties is equalized about a mean of $132,500 (+/- $21,400 [1 SD]) by varying reimbursement rates in such a way that the effect of working hours is fully discounted. Reimbursement rates under the proposed payment system make no recognition of the hours of professional effort, postgraduate specialty training, or putative differences in the nature of the physician's work.Conclusion: --The RBRVS, and the HCFA fee schedule to the extent that it is based on that scale, are inappropriate bases for the reform of the physician reimbursement system. [ABSTRACT FROM AUTHOR]

Objective: --To evaluate the usefulness of malpractice claims data for identifying (1) physicians who are prone to negligent errors and (2) physician and hospital characteristics associated with particular kinds of errors.Design: --Retrospective review of physician malpractice claim records.Setting: --Large New Jersey physician malpractice insurer.Participants: --Physicians practicing obstetrics and gynecology, general surgery, anesthesiology, or radiology and covered by the insurance carrier for any portion of 1977 through 1989.Main Outcome Measures: --Claims were classified into 11 clinical error categories comprising three broad groups: patient management problems, technical performance problems, and staff coordination problems. Outcomes were expressed as per-physician frequency of claims due to negligence and proportion of claims associated with various types of errors.Results: --Using 5 years of claims history to predict long-term claims proneness was more accurate than chance alone by 57% in obstetrics and gynecology, 33% in general surgery, 11% in anesthesiology, and 15% in radiology. Cross-validated recursive partitioning showed that among physician characteristics, only specialty was predictive of physician error profiles. For physician claims arising in acute care hospitals, hospital size and location in addition to hospital services discriminated among different error profiles; the cross-validated accuracy of this method was 69% compared with 22% accuracy achieved by random prediction.Conclusion: --Use of physicians' malpractice claims histories to target individuals for education or sanctions is problematic because of the only modest predictive power of such claims histories. [ABSTRACT FROM AUTHOR]

Objective: --To identify potentially preventable sources of medical injury in obstetrics and gynecology, general surgery, anesthesiology, and radiology.Design: --Retrospective review of physician malpractice claim records.Setting: --Large New Jersey physician malpractice insurer.Participants: --Physicians practicing obstetrics and gynecology, general surgery, anesthesiology, and radiology and covered by the insurance carrier during any portion of 1977 through 1989.Main Outcome Measures: --Proportion of claims due to negligence associated with errors in (1) patient management, (2) technical performance, and (3) medical and nursing staff coordination and the clinical and financial consequences of such errors.Results: --Among 1371 claims ascribed to negligence, patient management errors were cited most frequently in all four specialties (48% to 75%) and, compared with performance and coordination problems, were generally associated with a higher frequency of serious injury and higher median payments. Coordination problems accounted for about 9% of claims. In obstetrics and gynecology, newborn delivery claims usually arose from management errors (57% to 68%), whereas gynecologic procedure claims were most often associated with performance errors (55% to 73%). Underperformance of cesarean section was cited more frequently than overperformance (31% vs 3%). General surgery claims were about equally divided between management and performance types regardless of procedure. Failure to perform appropriate diagnostic testing or monitoring was the main problem in 3% to 8% of claims.Conclusion: --Malpractice data can be used to identify problem-prone clinical processes and suggest interventions that may reduce negligence. [ABSTRACT FROM AUTHOR]

The types of intensive care are multiple. The aim of this multicentric study was to describe activity of different ICUs using the same methods. 38 ICU were chosen by cooption, not randomization. Collected data concerned input (age, previous health status (HS), Simplified Acute Physiology Score or SAPS, Intensive Care Group (ICG), processes (TISS points), percentage of ventilated patients and pulmonary arterial lines and outcome (ICU death rate). The 3 ICG were: M = medical: all the none surgical patients; S = surgical patients operated in emergency setting during the week preceding or following ICU admission; E = surgical patients whose admission to ICU was scheduled at least 24 h before because of elective surgery. 3,687 patients were studied, classified as follows: M = 2175; S = 885; E = 627. The first part of the results concerned the differences between the three ICG: inputs, processes and outcome were very different in the three groups M, S, E, particularly in the E (elective) group, where therapeutic level was higher for low SAPS and mortality lower for high SAPS. The second part of the results concerns the differences between the ICUs. Intermediate units had older, less severe, and mainly medical patients. Surgical patients had better previous health status, were younger and scheduled for 40%. TISS points were higher, mainly by a higher rate of ventilated patients and patients with pulmonary artery lines on the first day. Specialized units characteristics depended mainly on the ICG.(ABSTRACT TRUNCATED AT 250 WORDS) [ABSTRACT FROM AUTHOR]

Objectives: To examine length of stay (LOS) and readmission rates for all minimally-invasive partial nephrectomy (MIPN) and MI radical nephrectomy (MIRN) performed for localized renal masses ≤7 cm in size (cT1RM) within 12 Michigan urology practices. Both RN and PN are commonly performed in treating cT1RM. Although technically more complex and associated with higher complication rates, Centers for Medicare & Medicaid Services considers MIPN an outpatient procedure and MIRN is inpatient.Methods: We collected data for renal surgeries for cT1RM at MUSIC-KIDNEY practices between May 2017-February 2020. Data abstractors recorded clinical, radiographic, pathologic, surgical, and short-term follow-up data into the registry for cT1RM patients.Results: Within MUSIC-KIDNEY, 807 patients underwent MI renal surgery at 12 practices. Median LOS for cT1RM patients after MIPN (n = 531, 66%) was 2 days and after MIRN (n = 276, 34%) was also 2 days. Among patients undergoing laparoscopic or robotic PN, 171 (32%), 230 (43%), and 130 (24%) stayed ≤1, 2, ≥3 days. Among patients undergoing laparoscopic or robotic RN, 81 (29%), 112 (41%), and 83 (30%) stayed ≤1, 2, ≥3 days. No significant difference was observed between MIPN and MIRN on LOS commensurate with outpatient surgery (≤1-day, OR = 0.97, P = 0.87).Conclusions: Less than one-third of patients had a LOS ≤1-day and LOS was comparable for MIPN and MIRN. Centers for Medicare & Medicaid Services should be advised that MIPN is a more complex surgery than MIRN, most patients receiving a MIPN will require a ≥2-day hospital stay and it would be more appropriate to classify MIPN an inpatient procedure with MIRN. [ABSTRACT FROM AUTHOR]

Objective: To devise a six-week hands-on training program customized to meet the needs of practicing general surgeons. The aim of this program is to provide the required training experience that will bestow the knowledge and skill necessary to implement a successful practice in laparoscopic bariatric surgery.Methods: Ten board-certified/board-eligible practicing general surgeons with no prior hands-on or formal training in laparoscopic bariatric surgery. We report on the participants training experience and the impact that the program had on their subsequent laparoscopic bariatric clinical activity.Results: Ten surgeons completed training programs from 9/01 to 3/03. None of the trainees had prior experience in laparoscopic bariatric surgery. Program operative experience averaged 42 cases (range 29-66). Trainees were integrated into all preoperative and postoperative hospital and outpatient care on the service, including workshops and seminars. Seven graduates are in practice performing laparoscopic bariatric surgery and three are implementing new bariatric programs. The active surgeons report performing an average of 101 laparoscopic bariatric procedures (range 18-264) over a mean practice period of 10 months (range 4-16)Conclusion: A six-week focused mini-fellowship with hands-on operative and clinical participation enables practicing surgeons to acquire the skill and experience necessary to successfully implement a laparoscopic bariatric surgical practice. [ABSTRACT FROM AUTHOR]

Relation between the number of cases treated and outcome, particularly in low-incidence anomalies, are difficult to identify and rectify. We show clear advantages in speech outcomes for children born with a cleft lip and palate who are operated on by surgeons who do large numbers of these procedures. [ABSTRACT FROM AUTHOR]