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Introduction Patient Safety Indicator (PSI) 90 is a composite measure widely used in federal pay-for-performance and public reporting programs. A component metric of PSI 90, venous thromboembolism (VTE) rate, has been shown to be subject to surveillance bias and not a valid measure for hospital quality comparisons. A study was conducted to examine how hospital PSI 90 scores would change if the VTE measure were removed from calculation of this composite measure. Methods Using 2014 Medicare inpatient claims data, PSI 90 scores were calculated with and without the VTE measure for 3,203 hospitals. Hospital characteristics obtained from the American Hospital Association Annual Survey and Centers for Medicare & Medicaid Services Payment Update Impact File were merged with PSI 90 scores. Results Removing the VTE outcome measure from the calculation of PSI 90 version 5 improved PSI 90 scores for 17.1% of hospitals but lowered scores for 20.8% of hospitals, while 62.1% had no change in scores. Hospitals were more likely to improve on PSI 90 when the VTE measure was removed if they were larger (odds ratio [OR] = 1.60; 95% confidence interval [CI] = 1.00–2.58), were major teaching hospitals (OR = 1.76; 95% CI = 1.10–2.79), had greater technological resources (OR = 2.03; 95% CI = 1.40–2.94), or cared for sicker patients (OR = 1.12; 95% CI = 1.01–1.25). Conclusion Inclusion of the surveillance bias–prone VTE outcome measure in the PSI 90 composite disproportionately penalizes larger, academic hospitals and those that care for sicker patients. Removal of the VTE outcome measure from PSI 90 should be strongly considered.

Importance Differences in medical school experiences may affect how prepared residents feel themselves to be as they enter general surgery residency and may contribute to resident burnout. Objectives To assess preparedness for surgical residency, to identify factors associated with preparedness, to examine the association between preparedness and burnout, and to explore resident and faculty perspectives on resident preparedness. Design, Setting, and Participants This cross-sectional study used convergent mixed-methods analysis of data from a survey of US general surgery residents delivered at the time of the 2017 American Board of Surgery In-Training Examination (January 26 to 31, 2017) in conjunction with qualitative interviews of residents and program directors conducted as part of the Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) trial. A total of 262 Accreditation Council for Graduate Medical Education–approved US general surgery residency programs participated. Survey data were collected from 3693 postgraduate year (PGY) 1 and PGY2 surgical residents (response rate, 99%) and 98 interviews were conducted with residents and faculty from September 1 to December 15, 2018. Data were analyzed from June 1, 2017, to February 15, 2018. Main Outcomes and Measures Hierarchical regression models were developed to examine factors associated with preparedness and to assess the association between preparedness and resident burnout. Qualitative interviews were conducted to identify themes associated with preparation for residency. Results Of the 3693 PGY1 and PGY2 residents who participated (2258 male [61.1%]), 1775 (48.1%) reported feeling unprepared for residency. Approximately half of surgery residents took overnight call infrequently (≤2 per month) during their core medical student clerkship (1904 [51.6%]) or their subinternship (1600 [43.3%]); 524 (14.2%) took no call during their core clerkship. In multivariable analysis, residents were more likely to report feeling unprepared for residency if they were female (odds ratio [OR], 1.34; 95% CI, 1.15-1.57) or did not take call as a medical student (OR for 0 vs >4 calls, 2.72; 95% CI, 2.10-3.52). Residents who did not complete a subinternship were less likely to report feeling prepared for residency (OR, 0.68; 95% CI, 0.48-0.96). Feeling adequately prepared for residency was associated with a nearly 2-fold lower risk of experiencing burnout symptoms (OR, 0.57; 95% CI, 0.48-0.68). In interviews, the dominant themes associated with preparedness included the following: (1) various regulations limit the medical school experience, (2) overnight call facilitates preparation and selection of a specialty compatible with their preferences, and (3) adequate perceptions of residency improve expectations, resulting in improved preparedness, lower burnout rates, and lower risk of attrition. Conclusions and Relevance In this cross-sectional study, the perception of feeling unprepared was associated with inadequate exposure to resident responsibilities while in medical school. These findings suggest that effective preparation of medical students for residency may result in lower rates of subsequent burnout.

Background Adverse postoperative outcomes related to smoking are well established, yet current smokers continue to be offered elective surgery in the US. It is unknown whether patients undergoing low-risk, elective procedures, who actively smoke experience increased risk of complications. We sought to determine the increased burden of complications following elective hernia repair procedures in patients identified as current smokers. Methods We identified patients undergoing elective incisional, inguinal, umbilical, or ventral hernia repair from 2011 to 2014 using the American College of Surgeons National Surgical Quality Improvement Project (ACS NSQIP) database. Multivariable logistic regression analysis was used to examine the association between current smoking and 30-day postoperative outcomes, adjusting for demographics and comorbidities. Results Of 220,629 patients who underwent elective hernia repair, 40,446 (18.3%) self-identified as current smokers within the past 12 months. Current smokers experienced an increased likelihood (Odds Ratio [95% Confidence interval]) of reoperation (OR 1.23 [95% CI 1.11–1.36]), readmission (OR 1.24 [95% CI 1.16–1.32]), and death (OR 1.53 [95% CI 1.06–2.22]). Furthermore, smokers experienced an increased risk of postoperative pulmonary, infectious, and wound complications, but there was no increased risk of requiring transfusion or of postoperative cardiac or thromboembolic events. Conclusions Current smokers were more likely to experience serious postoperative complications within 30 days. Given the volume of elective hernia surgery performed in the US, encouraging smoking cessation prior to offering elective repair could reduce postoperative complications, reoperation, readmission, and mortality.

BACKGROUND: Surgeons play a pivotal role in the opioid epidemic but it is unknown how different members of a surgical team vary in the way they prescribe opioids after surgical episodes. STUDY DESIGN: We conducted a retrospective cohort study of all inpatient discharges for 5 common surgeries. Total number of tablets and total milligram equivalents (MME) prescribed were calculated and differences in prescription patterns were determined for attending surgeons, surgical residents and advanced practice providers. Using a generalized ordered logistic regression, we examined factors associated with ordering a higher number of tablets or MME. RESULTS: The median number of tablets (range) prescribed by rank were attending surgeon 30 (6–72), surgical resident 20 (6–189) and advanced care practitioner 40 (5–1000); p

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.

Background Recurrent ischemic events have been associated with delayed carotid endarterectomy (CEA) for patients who present with acute strokes. As such, earlier intervention has been advocated to preserve cerebral function and expedient rehabilitation. We sought to determine the differences in 30-day postoperative major adverse clinical events (MACEs) for patients who undergo early (≤7 days) and delayed (>7 days) CEA after acute stroke. Methods Our sample consisted of patients captured in the CEA-targeted American College of Surgeons National Surgical Quality Improvement Program data set between 2011 and 2015. The primary outcome was 30-day postoperative MACEs (death, stroke, or myocardial infarction [MI]). Differences in postoperative MACEs were determined between early and delayed CEA treatment. In addition, multivariable analyses were done to determine the association between various patient factors and postoperative complications after CEA for patients who presented with acute strokes. Results A total of 3,427 patients were identified who underwent CEA for acute stroke in the CEA-targeted files between 2011 and 2015. Overall, perioperative rates of 30-day death, stroke, or MI were 1.30% (n = 43), 2.74% (n = 94), and 0.96% (n = 33), respectively. There were no differences in 30-day postoperative death, stroke, or MI for early or delayed CEA after acute strokes. On multivariable analysis, independent predictors for postoperative MACEs in patients with acute stroke were age ≥80 years (OR 2.41; 95% CI [1.15–5.06]), preoperative beta-blocker use (OR 2.11; 95% CI [1.13–3.93]), and operative time > 150 min (OR 2.39; 95% CI [0.82–4.98]). Conclusions There are no differences in postoperative 30-day death, stroke, or MI in early and delayed CEA after an acute stroke. These results substantiate the recommendation for early (

Background Surgical site infection (SSI) poses a significant burden to patients and healthcare resources. Vascular Quality Initiative (VQI) data identify a higher rate of SSIs for lower extremity bypass than other vascular procedures. Bundled interventions have successfully reduced SSIs in other surgical procedures. Study Design We evaluated our institution-specific VQI data for modifiable risk factors associated with index hospitalization SSI from January 2012 through October 2015. We implemented an evidence-based lower extremity bypass operation SSI reduction bundle (ie perioperative chlorhexidine showers and transverse groin incisions) and prospectively enrolled all patients who had lower extremity bypass procedures, with a target adherence rate of 50% per bundle component. Bundle adherence and SSI events were measured from March 2016 through August 2017. We carried out a pre-post evaluation of bundle effectiveness in reducing index hospitalization SSI. Results In the pre-intervention period, 43 of 234 (18%) patients had SSI events. The only risk factors associated with SSI (ie female sex, diabetes, overweight BMI) were not readily modifiable. In an 18-month period after introduction of our intervention, adherence rates to preoperative chlorhexidine showers, a transverse incision, and a postoperative chlorhexidine shower were 71% (52 of 73), 48% (24 of 50), and 88% (64 of 73), respectively. Compliance with all applicable bundle components was 36% (26 of 73). The SSI rate post-intervention decreased from 18% to 4% (3 of 73). Intention-to-treat multivariable analysis showed a 97% SSI risk reduction with the bundle (p = 0.002). As-treated analysis identified 85% (p = 0.02) and 62% (p = 0.047) SSI risk reductions from the preoperative and postoperative chlorhexidine showers, respectively. Conclusions In this evaluation study of the effectiveness of a quality improvement intervention, SSIs were markedly decreased after implementation of our evidence-based bundle for lower extremity vascular bypass procedures.

This secondary analysis of data from the FIRST trial examines the reasons surgical residents work beyond the 2011 duty hour restrictions for daily shifts established by the Accreditation Council for Graduate Medical Education.

Combined pulmonary insufficiency (PI) and stenosis (PS) is a common long-term sequela after repair of many forms of congenital heart disease, causing progressive right ventricular (RV) dilation and failure. Little is known of the mechanisms underlying this combination of preload and afterload stressors. We developed a murine model of PI and PS (PI+PS) to identify clinically relevant pathways and biomarkers of disease progression. Diastolic dysfunction was induced (restrictive RV filling, elevated RV end-diastolic pressures) at 1 month after generation of PI+PS and progressed to systolic dysfunction (decreased RV shortening) by 3 months. RV fibrosis progressed from 1 month (4.4% ± 0.4%) to 3 months (9.2% ± 1%), along with TGF-β signaling and tissue expression of profibrotic miR-21. Although plasma miR-21 was upregulated with diastolic dysfunction, it was downregulated with the onset of systolic dysfunction), correlating with RV fibrosis. Plasma miR-21 in children with PI+PS followed a similar pattern. A model of combined RV volume and pressure overload recapitulates the evolution of RV failure unique to patients with prior RV outflow tract surgery. This progression was characterized by enhanced TGF-β and miR-21 signaling. miR-21 may serve as a plasma biomarker of RV failure, with decreased expression heralding the need for valve replacement.

Endovascular aneurysm repair (EVAR) is considered the standard therapy for most patients with abdominal aortic aneurysm (AAA). Endoleak is a well-known EVAR-related complication that requires long-term follow-up. However, patient follow-up is often challenging outside clinical trials. We sought to evaluate the incidence and the effect of delayed endoleaks in a Veterans Administration (VA) health care system where long-term follow-up is ensured.We retrospectively evaluated 213 consecutive patients who underwent EVAR at a referral Veterans Administration medical center. Age, aneurysm size, patency of lumbar and inferior mesenteric arteries, and follow-up evaluations were recorded. Type of endoleak, date of detection, and intervention were also documented. Patients who had1 year of follow-up were excluded. The χ(2) test, Student t-test, Mann-Whitney test, and Spearman correlation were used for data analysis.The analysis included 183 patients with a mean follow-up of 53 months (range, 12-141 months); of these, 48 patients (26%) had endoleaks, and 31 (17%) had aneurysm progression. The mean diagnosis time for nontype II (n = 14) endoleaks was 45 months (range, 3-127 months), and 71% were diagnosed1 year after EVAR. All except one nontype II endoleak received prompt secondary interventions, and the one without intervention presented with aneurysm rupture. An isolated type II endoleak was detected in 34 patients at an average of 14.4 months (range, 0-76 months) after EVAR, 41% of which were detected1 year after EVAR. Patients without a documented endoleak had a significant decrease in aneurysm size at the latest computed tomography evaluation compared to the preoperative size (4.8 vs 5.7 cm; P.001), whereas those with isolated type II endoleak had an increase at the latest computed tomography follow-up compared to preoperative size (5.8 vs 5.7 cm). Importantly, 59% of the patients with a type II endoleak had significant AAA enlargement (0.8 cm), and delayed type II endoleak was significantly associated with sac enlargement compared to type II endoleaks detected early. No significant correlation was seen between the diameter of inferior mesenteric artery or lumbar to AAA enlargement among the patients with a type II endoleak. Secondary interventions in 12 patients with isolated type II endoleak resulted in overall aneurysm stabilization or regression.This long-term outcome study demonstrated that delayed endoleaks appearing1 year after EVAR contributed to most of the overall endoleaks and were significantly associated with aneurysm sac growth. This study underscores that type II endoleak is not benign and that vigilant lifelong surveillance after EVAR is critical.

The number and strength of opioids prescribed after surgery can vary widely at a single institution. Further research is needed to elucidate variations in prescribing., Introduction: Recent literature has shown a wide variation in the prescribing patterns of opioids after elective surgery. We conducted an evaluation of discharge opioid prescribing after elective surgical procedures to determine whether opioid-prescribing patterns varied at our institution. Method: A single academic medical center retrospective review of patients undergoing laparoscopic cholecystectomy, laparoscopic appendectomy, open umbilical hernia repair, simple mastectomy, or thyroidectomy between July 2015 and July 2016. Results: Among a total of 615 unique surgical cases, we found a wide variation in the number of pills and morphine milligram equivalents prescribed for each procedure evaluated. In addition, 94.8% of all patients discharged received a prescription for opioids, whereas only 15.6% of patients received a prescription for a nonopioid analgesic. Conclusion: The number and strength of opioids prescribed after surgery can vary widely at a single institution. Further research is needed to elucidate variations in prescribing.

This data analysis compares available outcome, patient experience, and behavioral health measures between Veterans Affairs and non–Veterans Affairs hospitals.

MicroRNAs (miRs) are crucial regulators of cardiac remodeling in left ventricular hypertrophy and failure (LVH/LVF). However, there is minimal data on their role in right ventricular hypertrophy and failure (RVH/RVF), a risk for patients with congenital heart disease or pulmonary hypertension. Utilizing a murine model of RVH/RVF, we have described RV-specific overexpression of miR-28, not found in LVH/LVF. We used this model to evaluate miR-28 regulation of its downstream target Nrf2, a master regulator of antioxidant defenses, and a potential mechanism of the enhanced susceptibility of the RV to fail under pressure overload. Methods: miR-28 and Nrf2 gene and protein expression and ROS production and antioxidant defenses were assessed at 10d in RVH/RVF (pulmonary artery banding) and LVH/LVF (aortic banding). miR-28 was overexpressed in HEK293 cells and Nrf2 and ROS production assessed. Plasma miRs were also profiled. Results: Mice developed RVH by d4, at which time miR-28 was not increased vs. sham, and RVF by d10, when miR-28 was increased 2-fold. This was accompanied by decreases in Nrf2 gene (2-fold) and protein (0.4±0.2 vs. 0.8±0.1, p Conclusions: Our data show that RV-specific miR-28 enhances RVH/RVF through suppression of Nrf2 signaling and increased oxidative stress. Although we did not find Nrf2 downregulation at the same stage of LVH/LVF, others have shown this at 4-6 wks, suggesting this process may occur earlier in RVF vs. LVF. Finally, miR-28 plasma expression may be a biomarker for early RVF in patients.

Coral reef aorta is an uncommon variant of atherosclerotic disease. We report a rare presentation of rapid renal function deterioration in a patient with coral reef plaque protruding into the renal orifices without significant disease elsewhere. The patient was successfully treated with aorta endarterectomy, resulting in complete resolution of renal dysfunction. This case highlights the importance of prompt intervention for renal rescue.

Background Disruption of CNS microvessels and CSF-bordering cells (ependyma, choroid plexus and leptomeninges) can alter fluid flow among the CNS compartments. This leads to hydrocephalus. An excess of basic fibroblast growth factor (FGF2) or amyloid precursor protein (APP), from which A-Beta fragments derive, predisposes to altered fluid dynamics and amyloid retention. We combined these risk factors to accelerate development of hydrocephalus. Hypothesis: Doubly-transgenic animals, overexpressed for FGF2 and APP, have greater morbidity in respect to compromised CSF turnover and toxic A-Beta effects. We also postulated CSF/brain and blood/brain interfaces to be especially vulnerable in double overexpression.