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Although the Social Vulnerability Index (SVI) was created to identify vulnerable populations after unexpected natural disasters, its ability to identify similar groups of patients undergoing unexpected emergency surgical procedures is unknown. We sought to examine the association between SVI and outcomes after emergency general surgery.This study is a cross-sectional review of 887,193 Medicare beneficiaries who underwent 1 of 4 common emergency general surgery procedures (appendectomy, cholecystectomy, colectomy, and ventral hernia repair) performed in the urgent or emergent setting between 2014 and 2018. These data were merged with the SVI at the census-track level of residence. Risk-adjusted outcomes (30-day mortality, serious complications, readmission) were evaluated using a logistic regression model accounting for age, sex, comorbidity, year, procedure type, and hospital characteristics between high and low social vulnerability quintiles and within the 4 SVI subthemes (socioeconomic status; household composition and disability; minority status and language; and housing type and transportation).Compared with beneficiaries with low social vulnerability, Medicare beneficiaries living in areas of high social vulnerability experienced higher rates of 30-day mortality (8.56% vs 8.08%; adjusted odds ratio 1.07; p0.001), serious complications (20.71% vs 18.40%; adjusted odds ratio 1.17; p0.001), and readmissions (16.09% vs 15.03%; adjusted odds ratio 1.08; p0.001). This pattern of differential outcomes was present in subgroup analysis of all 4 SVI subthemes but was greatest in the socioeconomic status and household composition and disability subthemes.National efforts to support patients with high social vulnerability from natural disasters may be well aligned with efforts to identify communities that are particularly vulnerable to worse postoperative outcomes after emergency general surgery. Policies targeting structural barriers related to household composition and socioeconomic status may help alleviate these disparities.

The Center of Medicare and Medicaid Services valued based payments for inpatient surgical hospitalizations are adjusted for clinical but not social risk factors. While research has shown that social risk is associated with worse surgical patient outcomes, it is unknown if inpatient surgical episode Medicare payments are affected by social risk factors.Retrospective review of Medicare beneficiaries, age 65-99, undergoing appendectomy, colectomy, hernia repair, or cholecystectomy between 2014 and 2018. Neighborhood deprivation measured by Area Deprivation Index for beneficiary census tract. We evaluated Medicare payments for a total episode of surgical care comprised of index hospitalization, physician fees, post-acute care, and readmission by beneficiary neighborhood deprivation.A total of 809,059 patients (Women, 56.0%) and mean (SD) age of 75.7 (7.4 years were included. A total of 145,351 beneficiaries lived in the least deprived neighborhoods and 134,188 who lived in the most deprived neighborhoods. Total surgical episode spending was $2654 higher among beneficiaries from the most deprived neighborhoods compared to those from the least after risk adjustment for clinical and hospital factors. These differences were driven in part by higher rates of readmissions (12.9% vs 10.8%, P 0.001) and post-acute care (67.8% vs. 61.2%, P 0.001) among beneficiaries living in the most deprived neighborhoods.These findings suggest that value-based payment models with inclusion of social risk adjustment may be needed for surgical cohorts. Moreover, efforts focused on investing in deprived communities may be aligned with surgical quality improvement.

Collaborative quality improvement is an established method to conduct quality improvement in surgical care. Despite the success of this method, little is known about the experiences, perceptions, and attitudes of those who participate in collaborative quality improvement. The following study elicited common themes associated with the experiences and perceptions of surgeons participating in collaborative quality improvement.We conducted an interpretive description qualitative study of surgeons participating in the Michigan Surgical Quality Collaborative, which is a statewide collaborative quality improvement consortium in Michigan. Semi-structured interviews were conducted using an interview guide.A sample of 24 participants completed interviews with a mean (SD) age of 48.7 (11.5) years and 16 (80%) male participants. Two major themes were identified. First, the contextualization of individual performance was seen as key to identifying opportunities for improvement and creating motivation to improve. Contextualization of individual performance relative to peer performance was collaborative rather than punitive. Second, peer learning emerged as the primary way to inform practice change and overcome hesitancy to change. Rather than draw upon external evidence, practice change within the collaborative was informed by the practices of peer institutions. Both themes were strongly exemplified in one of the Michigan Surgical Quality Collaborative's largest initiatives-reducing excessive postoperative opioid prescribing.In this qualitative study of surgeons participating in statewide collaborative quality improvement, contextualization of individual outcomes and peer learning were the most salient themes. Collaborative quality improvement relied upon comparing one's own performance to peer performance, motivating improvement using this comparison, deriving evidence from peers to inform improvement initiatives, and overcoming hesitancy to change by highlighting peer success.

To compare safety and healthcare utilization after sleeve gastrectomy versus Roux-en-Y gastric bypass in a national Medicare cohort.Though bariatric surgery is increasing among Medicare beneficiaries, no long-term, national studies examining comparative effectiveness between procedures exist. Bariatric outcomes are needed for shared decision-making and coverage policy concerns identified by the cMS Medicare Evidence Development and Coverage Advisory Committee.Retrospective instrumental variable analysis of Medicare claims (2012-2017) for 30,105 bariatric surgery patients entitled due to disability or age. We examined clinical safety outcomes (mortality, complications, and reinterventions), healthcare utilization [Emergency Department (ED) visits, rehospitalizations, and expenditures], and heterogeneity of treatment effect. We compared all outcomes between sleeve and bypass for each entitlement group at 30 days, 1 year, and 3 years.Among the disabled (n = 21,595), sleeve was associated with lower 3-year mortality [2.1% vs 3.2%, absolute risk reduction (ARR) 95% confidence interval (CI): -2.2% to -0.03%], complications (22.2% vs 27.7%, ARR 95%CI: -8.5% to -2.6%), reinterventions (20.1% vs 27.7%, ARR 95%CI: -10.7% to -4.6%), ED utilization (71.6% vs 77.1%, ARR 95%CI: -8.5% to -2.4%), and rehospitalizations (47.4% vs 52.3%, ARR 95%Ci: -8.0% to -1.7%). Cumulative expenditures were $46,277 after sleeve and $48,211 after bypass (P = 0.22). Among the elderly (n = 8510), sleeve was associated with lower 3-year complications (20.1% vs 24.7%, ARR 95%CI: -7.6% to -1.7%), reinterventions (14.0% vs 21.9%, ARR 95%CI: -10.7% to -5.2%), ED utilization (51.7% vs 57.2%, ARR 95%CI: -9.1% to -1.9%), and rehospitalizations (41.8% vs 45.8%, ARR 95%Ci: -7.5% to -0.5%). Expenditures were $38,632 after sleeve and $39,270 after bypass (P = 0.60). Procedure treatment effect significantly differed by entitlement for mortality, revision, and paraesophageal hernia repair.Bariatric surgery is safe, and healthcare utilization benefits of sleeve over bypass are preserved across both Medicare elderly and disabled subpopulations.

To evaluate if receipt of complex cancer surgery at high quality hospitals is associated with a reduction in disparities between individuals living in the most and least deprived neighborhoods.The association between social risk factors and worse surgical outcomes for patients undergoing high-risk cancer operations is well documented. To what extent neighborhood socioeconomic deprivation as an isolated social risk factor known to be associated with worse outcomes can be mitigated by hospital quality is less known.Using 100% Medicare fee-for-service claims, we analyzed data on 212,962 Medicare beneficiariesage 65 undergoing liver resection, rectal resection, lung resection, esophagectomy and pancreaticoduodenectomy for cancer between 2014 and 2018. Clinical risk-adjusted 30-day post-operative mortality rates were used to stratify hospitals into quintiles of quality. Beneficiaries were stratified into quintiles based on census tract Area Deprivation Index. The association of hospital quality and neighborhood deprivation with 30-day mortality was assessed using logistic regression.There were 212,962 patients in the cohort including 109,419(51.4%) men with mean (SD) age of 73.8(5.9) years old. At low-quality hospitals, patients living in the most deprived areas had significantly higher risk-adjusted mortality than those from the least deprived areas for all procedures; esophagectomy: 22.3% versus 20.7%; P0.003, liver resection 19.3% versus 16.4%; P0.001, pancreatic resection 15.9% versus 12.9%; P0.001, lung resection 8.3% versus 7.8%; P0.001, rectal resection 8.8% versus 8.1%; P0.001. Surgery at a high-quality hospitals was associated with no significant differences in mortality between individuals living in the most compared to least deprived neighborhoods for esophagectomy, rectal resection, liver resection and pancreatectomy. For example, the adjusted odds of mortality between individuals living in the most deprived compared to least deprived neighborhoods following esophagectomy at low quality hospitals (OR 1.22; 95% CI 1.14-1.31; P0.001) was higher than at high quality hospitals (OR 0.98, 95%CI 0.94-1.02; P=0.03).Receipt of complex cancer surgery at a high-quality hospital was associated with no significant differences in mortality between individuals living in the most deprived neighborhoods compared to least deprived. Initiatives to increase access referrals to high quality hospitals for patients from high deprivation levels may improve outcomes and contribute to mitigating disparities.

The taxing nature of surgery residency is well-documented in the literature, with residents demonstrating high rates of burnout, depression, suicidal thoughts, sexual harassment, and racial discrimination. Mentoring has been shown to improve camaraderie, address challenges of underrepresentation in medicine, and be associated with lower burnout. However, existing formal mentoring programs tend to be career-focused and hierarchal without opportunity to discuss important sociocultural issues. An innovative approach is needed to address these cultural and anthropological issues in surgery residencies while creating camaraderie and learning alternative perspectives across different levels of training. We sought to describe the framework we used to fill these needs by creating and implementing a novel mentoring program.A vertical, near-peer mentoring system of 7 groups was created consisting of the following members: 1 to 2 medical students, a PGY-1 general surgery resident, a PGY-4 research resident, and a faculty member. Meetings occur every 3 to 4 months in a casual setting with the first half of the meeting dedicated to intentional reflection and the second half focused on an evidence-based discussion regarding a specific topic in the context of surgery (i.e., burnout, discrimination, allyship, and finding purpose).Program implementation took place at the University of Michigan in Ann Arbor, MI.Medical students, general surgery residents, and general surgery faculty were recruited.We have successfully launched the pilot year of a cross-spectrum formal mentoring program in general surgery. This program emphasizes camaraderie throughout training while providing opportunities for evidence-based discussion regarding sociocultural topics. We have included increased opportunities for community inclusivity and mentoring while allowing trainees and faculty members to discuss sensitive topics in a supportive environment. We plan to continue developing the program with robust evaluation and to expand the program to other surgical specialties and to other institutions.

Compare adverse outcomes up to 5 years after sleeve gastrectomy and gastric bypass in patients with Medicaid.Sleeve gastrectomy is the most common bariatric operation among patients with Medicaid, however its long-term safety in this population is unknown.Using Medicaid claims, we performed a retrospective cohort study of adult patients who underwent sleeve gastrectomy or gastric bypass from January 1, 2012 to December 31, 2018. Instrumental variables survival analysis was used to estimate the cumulative incidence and heterogeneity of outcomes up to 5 years after surgery.Among 132,788 patients with Medicaid, 84,717 (63.8%) underwent sleeve gastrectomy and 48,071 (36.2%) underwent gastric bypass. 69,225 (52.1%) patients were White, 33,833 (25.5%) were Black, and 29,730 (22.4%) were Hispanic. Compared to gastric bypass, sleeve gastrectomy was associated with a lower 5-year cumulative incidence of mortality (1.29% vs. 2.15%), complications (11.5% vs. 16.2%), hospitalization (43.7% vs. 53.7%), ED use (61.6% vs. 68.2%), and reoperation (18.5% vs. 22.8%), but a higher cumulative incidence of revision (3.3% vs. 2.0%). Compared to White patients, the magnitude of the difference between sleeve and bypass was smaller among Black patients for ED use (5-year aHR 1.01 [95% CI 0.94-1.08] vs. 0.94 [95% CI 0.88-1.00], P0.001) and Hispanic patients for reoperation (5-year aHR 0.95 [95% CI 0.86-1.05] vs. 0.76 [95% CI 0.69-0.83], P0.001).Among patients with Medicaid undergoing bariatric surgery, sleeve gastrectomy was associated with a lower risk of mortality, complications, hospitalization, ED use, and reoperations, but a higher risk of revision compared to gastric bypass. Although the difference between sleeve and bypass was generally similar among White, Black, and Hispanic patients, the magnitude of this difference was smaller among Black patients for ED use and Hispanic patients for reoperation.

Surgical coaching interventions have been recommended as a method of technological skills improvement for individual surgeons and lifelong occupational learning. Patient outcomes for laparoscopic colectomy vary significantly based on surgeon experience and case volume. As surgical coaching is an emerging area, little is known about how surgeons view coaching interventions.Semistructured interviews with 68 colorectal surgeons from across the country who were e-mail recruited from the American Society of Colon and Rectal Surgeons focused on exploring the attitudes surrounding surgical coaching programs among colorectal surgeons. Interviews were performed via telephone, audio-recorded, and transcribed verbatim with redaction of identifying information. Interviews were analyzed by iterative steps informed by thematic analysis.Surgeons reported the desire to participate in coaching programs to improve patient outcomes through technical skill advancement, to keep pace with surgical innovation, and to fulfill a desire for lifelong learning. However, surgeons varied in their beliefs over who should be coached, who should coach, the format of coaching, and the topics addressed in coaching. Obstacles identified included time, financial and medicolegal concerns, balance with resident education, and vulnerability.Widespread enthusiasm for surgical coaching programs exists among colorectal surgeons. However, there is variability in what surgeons believe an ideal surgical coaching program would look like. Therefore, in alignment with adult learning theory, we recommend the creation of several different models of surgical coaching to allow each surgeon to benefit from this advancement in continuous professional development.

Americans living in Health Professional Shortage Areas (HPSA) only have 44% of the required physician workforce to service their residents. We sought to determine whether residents living in HPSA have worse surgical outcomes than those living in non-HPSA.We performed a retrospective review of 1,507,834 Medicare beneficiaries undergoing appendectomy, cholecystectomy, colectomy or hernia repair between 2014 and 2018. Multivariable logistical regression was used to determine the association of living in HPSA with rates of 30-day mortality.Compared with patients living in non-HPSA, patients living in HPSA traveled farther (median distance 35.3 miles vs. 11.7 miles, p 0.001) and longer (median 45 min vs. 20 min, p 0.001) for surgical care. Differences in rates of mortality between patients living in HPSA and non-HPSA (6.0% vs. 6.1%, OR = 0.97, 95% CI 0.97-0.97, p 0.001) were small.Medicare beneficiaries living in HPSA experience more than double the travel time and triple the travel distance to undergo common surgical procedures compared to those living in non-HPSA. For those able to overcome the travel burden, the differences in surgical outcomes were small.

IMPORTANCE: The association between physician fatigue and patient outcomes is important to understand but has been difficult to examine given methodological and data limitations. Surgeons frequently perform urgent procedures overnight and perform additional procedures the following day, which could adversely affect outcomes for those daytime operations. OBJECTIVE: To examine the association between an attending surgeon operating overnight and outcomes for operations performed by that surgeon the next day. DESIGN, SETTING, AND PARTICIPANTS: In this cross-sectional study, a retrospective analysis of a large multicenter registry of surgical procedures was done using a within-surgeon analysis to address confounding, with data from 20 high-volume US institutions. This study included 498 234 patients who underwent a surgical procedure during the day (between 7 am and 5 pm) between January 1, 2010, and August 30, 2020. EXPOSURES: Whether the attending surgeon for the current day’s procedures operated between 11 pm and 7 am the previous night. Two exposure measures were examined: whether the surgeon operated at all the previous night and the number of hours spent operating the previous night (including having performed no work at all). MAIN OUTCOMES AND MEASURES: The primary composite outcome was in-hospital death or major complication (sepsis, pneumonia, myocardial infarction, thromboembolic event, or stroke). Secondary outcomes included operation length and individual outcomes of death, major complications, and minor complications (surgical site infection or urinary tract infection). RESULTS: Among 498 234 daytime operations performed by 1131 surgeons, 13 098 (2.6%) involved an attending surgeon who operated the night before. The mean (SD) age of the patients who underwent an operation was 55.3 (16.4) years, and 264 740 (53.1%) were female. After adjusting for operation type, surgeon fixed effects, and observable patient characteristics (ie, age and comorbidities), the adjusted incidence of in-hospital death or major complications was 5.89% (95% CI, 5.41%-6.36%) among daytime operations when the attending surgeon operated the night before compared with 5.87% (95% CI, 5.85%-5.89%) among daytime operations when the same surgeon did not (absolute adjusted difference, 0.02%; 95% CI, −0.47% to 0.51%; P = .93). No significant associations were found between overnight work and secondary outcomes except for operation length. Operating the previous night was associated with a statistically significant decrease in length of daytime operations (adjusted length, 112.7 vs 117.4 minutes; adjusted difference, −4.7 minutes; 95% CI, −8.7 to −0.8, P = .02), although this difference is unlikely to be meaningful. CONCLUSIONS AND RELEVANCE: The findings of this cross-sectional study suggest that operating overnight was not associated with worse outcomes for operations performed by surgeons the subsequent day. These results provide reassurance concerning the practice of having attending surgeons take overnight call and still perform operations the following morning.

To compare out-of-pocket (OOP) costs for patients up to 3 years after bariatric surgery in a large, commercially-insured population.More information on OOP costs following bariatric surgery may affect patients' procedure choice.Retrospective study using the IBM MarketScan commercial claims database, representing patients nationally who underwent laparoscopic sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) January 1, 2011 to December 31, 2017. We compared total OOP costs after the surgical episode between the 2 procedures using difference-in-differences analysis adjusting for demographics, comorbidities, operative year, and insurance type.Of 63,674 patients, 64% underwent SG and 36% underwent RYGB. Adjusted OOP costs after SG were $1083, $1236, and $1266 postoperative years 1, 2, and 3. For RYGB, adjusted OOP costs were $1228, $1377, and $1369. In our primary analysis, SG OOP costs were $122 (95%CI: -$155 to -$90) less than RYGB year 1. This difference remained consistent at -$119 (95%CI: -$158 to -$79) year 2 and -$80 (95%CI: -$127 to -$35) year 3. These amounts were equivalent to relative differences of -7%, -7%, and -5% years 1, 2, and 3. Plan features contributing the most to differences were co-insurance years 1, 2, and 3.. The largest clinical contributors to differences were endoscopy and outpatient care year 1, outpatient care year 2, and emergency department use year 3.Our study is the first to examine the association between bariatric surgery procedure and OOP costs. Differences between procedures were approximately $100 per year which may be an important factor for some patients deciding whether to pursue SG or gastric bypass.

To characterize incidence and outcomes for bariatric surgery patients who give birth.Patients of childbearing age comprise 65% of bariatric surgery patients in the United States, yet data on how often patients conceive and obstetric outcomes are limited.Using the IBM MarketScan database, we performed a retrospective cohort study of female patients ages 18-52 undergoing laparoscopic sleeve gastrectomy or Roux-en-Y gastric bypass from 2011-2017. We determined incidence of births in the first two years after bariatric surgery using Kaplan-Meier estimates. We then restricted the cohort to those with full two-year follow-up to examine obstetric outcomes and bariatric-related reinterventions. We reported event rates of adverse obstetric outcomes and delivery type. Adverse obstetric outcomes include pregnancy complications, severe maternal morbidity, and delivery complications. We performed multivariable logistic regression to examine associations between birth and risk of reinterventions.Of 69,503 patients who underwent bariatric surgery, 1,464 gave birth. The incidence rate was 2.5 births per 100 patients in the 2 years after surgery. 85% of births occurred within 21 months after surgery. For 38,922 patients with full two-year follow-up, adverse obstetric event rates were 4.5% for gestational diabetes and 14.2% for hypertensive disorders. 48.5% were first-time Cesarean deliveries. Almost all reinterventions during pregnancy were biliary. Multivariable logistic regression analysis showed no association between post-bariatric birth and reintervention rate (OR: 0.93, 95%CI: 0.78-1.12).In this first national U.S. cohort, we find giving birth was common in the first 2 years after bariatric surgery and was not associated with increased risk of reinterventions. Clinicians should consider shifting the dialogue surrounding pregnancy after surgery to shared decisionmaking with maternal safety as one component.

Even after decades of network expansion and increased care being delivered within health networks, health network expansion has not led to uniform improvements in patient outcomes and satisfaction. The reasons for the lack of universal surgical quality improvement are unclear. This study used qualitative methods to understand the nuances that affect the variation in network-level surgical quality assurance and provides strategies that surgical leaders use to improve surgical quality at expanding health networks.This qualitative study obtained information through 30 semistructured interviews conducted from August to December 2019 with surgical leaders whose institutions were associated with health networks. The topic of surgical quality assurance was an emergent theme that was informed by thematic analysis.Interviews with leaders revealed 3 themes with regard to surgical quality assurance. First, participants wanted standardized tools for quality measurement. Leaders frequently referred to the National Surgical Quality Improvement Program registry and shared electronic health records, but some networks did not have these available at all sites. Second, participants wanted an organizational structure that provides clear oversight over quality. Some leaders appointed executives or created committees to help manage quality improvement initiatives. Third, participants wanted a culture shift toward quality improvement. Many leaders faced resistance to quality initiatives from frontline clinicians; some implemented events and retreats to help garner support and a culture of quality.These interviews offer critical insights into 3 domains that can be leveraged for sustained improvement and detail strategies that leaders used for surgical quality assurance at hospital networks.

IMPORTANCE: Sleeve gastrectomy and gastric bypass are the most common bariatric surgical procedures in the world; however, their long-term medication discontinuation and comorbidity resolution remain unclear. OBJECTIVE: To compare the incidence of medication discontinuation and restart of diabetes, hypertension, and hyperlipidemia medications up to 5 years after sleeve gastrectomy or gastric bypass. DESIGN, SETTING, AND PARTICIPANTS: This comparative effectiveness research study of adult Medicare beneficiaries who underwent laparoscopic sleeve gastrectomy or Roux-en-Y gastric bypass between January 1, 2012, to December 31, 2018, and had a claim for diabetes, hypertension, or hyperlipidemia medication in the 6 months before surgery with a corresponding diagnosis used instrumental-variable survival analysis to estimate the cumulative incidence of medication discontinuation and restart. Data analyses were performed from February to June 2021. EXPOSURES: Laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass. MAIN OUTCOMES AND MEASURES: The primary outcome was discontinuation of diabetes, hypertension, and hyperlipidemia medication for any reason. Among patients who discontinued medication, the adjusted cumulative incidence of restarting medication was calculated up to 5 years after discontinuation. RESULTS: Of the 95 405 patients included, 71 348 (74.8%) were women and the mean (SD) age was 56.6 (11.8) years. Gastric bypass compared with sleeve gastrectomy was associated with a slightly higher 5-year cumulative incidence of medication discontinuation among 30 588 patients with diabetes medication use and diagnosis at the time of surgery (74.7% [95% CI, 74.6%-74.9%] vs 72.0% [95% CI, 71.8%-72.2%]), 52 081 patients with antihypertensive medication use and diagnosis at the time of surgery (53.3% [95% CI, 53.2%-53.4%] vs 49.4% [95% CI, 49.3%-49.5%]), and 35 055 patients with lipid-lowering medication use and diagnosis at the time of surgery (64.6% [95% CI, 64.5%-64.8%] vs 61.2% [95% CI, 61.1%-61.3%]). Among the subset of patients who discontinued medication, gastric bypass was also associated with a slightly lower incidence of medication restart up to 5 years after discontinuation. Specifically, the 5-year cumulative incidence of medication restart was lower after gastric bypass compared with sleeve gastrectomy among 19 599 patients who discontinued their diabetes medication after surgery (30.4% [95% CI, 30.2%-30.5%] vs 35.6% [95% CI, 35.4%-35.9%]), 21 611 patients who discontinued their antihypertensive medication after surgery (67.2% [95% CI, 66.9%-67.4%] vs 70.6% [95% CI, 70.3%-70.9%]), and 18 546 patients who discontinued their lipid-lowering medication after surgery (46.2% [95% CI, 46.2%-46.3%] vs 52.5% [95% CI, 52.2%-52.7%]). CONCLUSIONS AND RELEVANCE: Findings of this study suggest that, compared with sleeve gastrectomy, gastric bypass was associated with a slightly higher incidence of medication discontinuation and a slightly lower incidence of medication restart among patients who discontinued medication. Long-term trials are needed to explain the mechanisms and factors associated with differences in medication discontinuation and comorbidity resolution after bariatric surgery.

Virtual forms of communication have been integrated into academic surgery now more than ever. The COVID-19 pandemic accelerated its implementation in an effort to support social-distancing. Academic surgery is now learning valuable lessons from early experiences to optimally integrate this communication mode. The Society of Asian Academic Surgeons convened an expert panel during the society's fifth annual meeting that explores these lessons. Realms of virtual communication including meetings, networking, surgery department administration, social media, application processes, and advice for early or mid-career academic surgeons are explored. Virtual conferences pose a new challenge by removing the in-person component that is evident to be integral to networking, collaboration, and all aspects of academic socialization. Strategies such as creating virtual chat rooms, mentor-mentee virtual introductions, and deliberate interactions can enhance the experience. Virtual administrative meetings require special attention to preparation and strategies to insure engagement. Social media can be a valuable tool to integrate into academic careers but special attention needs to be made to utilize it deliberately and not to shy away from our individuality. The interview process can be enhanced when made virtual to give opportunities to those typically disadvantaged in the usual, in-person process.

To compare surgical outcomes and expenditures at hospital network participating critical access hospitals to non-network participating critical access hospitals among Medicare beneficiaries.Critical access hospitals provide essential care to more than 80 million Americans. These hospitals, often rural, are located more than 35 miles away from another hospital and are required to maintain patient transfer agreements with other facilities capable of providing higher levels of care. Some have gone further to formally participate in a hospital network.Cross-sectional retrospective study from 2014-2018 comparing 16,128 Medicare beneficiary admissions at hospital network participating versus non-participating critical access hospitals undergoing appendectomy, cholecystectomy, colectomy, or hernia repair. Thirty-day mortality and readmissions were risk adjusted using multivariable logistic regression accounting for patient and hospital factors. Price-standardized, risk-adjusted Medicare expenditures were compared for the 30-day total episode payments consisting of index hospitalization, physician services, readmissions, and post-acute care payments.Beneficiaries (average age=75.7 y, SD=7.4) who obtained care at hospital network participating critical access hospitals were more likely to carry ≥2 Elixhauser comorbidities (68.7%vs.62.8%, P0.001). Rates of 30-day mortality were higher at hospital network participating critical access hospitals (4.30%vs.3.81%, OR=1.11, P0.001). Similarly, readmission rates were higher at hospital network participating critical access hospitals (15.13%vs.14.34%, OR=1.06, P0.001). Additionally, total episode payments were found to be $960 higher per patient at hospital network participating critical access hospitals ($23,878vs.$22,918, P0.001).Critical access hospitals within a hospital network provided care to more medically complex patients and were associated with worse clinical outcomes and higher costs among Medicare beneficiaries undergoing common general surgery operations.

To compare surgical outcomes and expenditures at hospitals located in Health Professional Shortage Areas to non-shortage area designated hospitals among Medicare beneficiaries.More than a quarter of Americans live in federally designated Health Professional Shortage Areas. While there is growing concern that medical outcomes may be worse, far less is known about hospitals providing surgical care in these areas.Cross sectional retrospective study from 2014-2018 of 842,787 Medicare beneficiary patient admissions to hospitals with and without Health Professional Shortage Area designations for common operations including appendectomy, cholecystectomy, colectomy, and hernia repair. Risk-adjusted outcomes using multivariable logistic regression accounting for patient factors, admission type, and year were compared for each of the four operations. Hospital expenditures were price-standardized, risk-adjusted 30-day surgical episode payments. Primary outcome measures included 30-day mortality, hospital readmissions, and 30-day surgical episode payments.Patients (mean age=75.6 y, males=44.4%) undergoing common surgical procedures in shortage area hospitals were less likely to be white (84.6%vs.88.4%, P0.001) and less likely to have≥2 Elixhauser comorbidities (75.5%vs.78.2%, P0.001). Patients undergoing surgery at Health Professional Shortage Area hospitals had lower risk-adjusted rates of 30-day mortality (6.05%vs.6.69%, OR=0.90, CI0.90-0.91, P0.001) and readmission (14.99%vs.15.74%, OR=0.94, CI=0.94-0.95, P0.001). Medicare expenditures at Health Professional Shortage Area hospitals were also lower than non-shortage designated hospitals ($28,517vs.$29,685, difference= -$1,168, P0.001).Patients presenting to Health Professional Shortage Area hospitals obtain safe care for common surgical procedures without evidence of higher expenditures among Medicare beneficiaries. These findings should be taken into account as current legislative proposals to increase funding for care in these under-served communities are considered.

Health Professional Shortage Areas (HPSA) were created by the Health Resources and Services Administration to identify communities with a shortage of clinical providers. For medical conditions, these designations are associated with worse outcomes. However, far less is known about patients undergoing high complexity surgical procedures, such as coronary artery bypass grafting (CABG).To compare post-operative surgical outcomes of high complexity surgery in beneficiaries living in HPSA versus non-HPSA designated areas.This study is a retrospective cohort review of Medicare beneficiaries who underwent CABG between 2014-2018. We compared risk-adjusted 30-day mortality, complication, reoperation, and readmission rates for beneficiaries living in a designated HPSA versus non-HPSA using a multivariable logistic regression model accounting for patient (e.g., age, sex, comorbidities, surgery year) and hospital characteristics (e.g., patient-to-nurse ratio, teaching status). Patient travel burden was measured based on the time and distance required to travel from the beneficiary's home zip code to the hospital zip code.Of the 370,532 Medicare beneficiaries who underwent CABG, 30,881 (8.3%) lived in a Health Professional Shortage Area. Beneficiaries in HPSAs were found to experience comparable 30-day mortality (3.50% vs. 3.65%, P0.001), complication (32.67% vs. 33.54%, P0.001), reoperation (1.58% vs. 1.66%, P0.001), and readmission (14.72% vs. 14.86%, P0.001) rates. Beneficiaries experienced greater mean travel times (91.2 minutes vs. 64.0 minutes, P0.001) and mean travel distances (85.0 miles vs. 59.3 miles, P0.001).Medicare beneficiaries living in designated Health Professional Shortage Areas experienced comparable surgical outcomes after coronary artery bypass graft surgery but a significantly greater travel burden. The greater travel burden experienced by patients living in designated shortage areas to obtain comparable surgical care for complex procedures demonstrates important tradeoffs between access and quality.

Objective To obtain novel perspectives regarding the effects that surgical training has on the well-being of trainees. Summary background data Improving trainee well-being is a national concern given high rates of burnout, depression, and suicide among physicians. Supporters of surgical trainees may offer new perspectives regarding the effects of surgical training and point to strategies to optimize trainee wellness. Methods This qualitative study employs semi-structured interviews of 32 support persons of trainees at a single tertiary care center with multiple surgical training programs. Interviews focused on perspectives related to supporting a surgical trainee. Interview transcripts underwent qualitative analysis with semantic and conceptual coding. Themes related to effects of training on trainee wellness are reported. Results Four themes were identified: (1)Who Can Endure the Most Hardship?-trainee attributes and programmatic factors contribute to trainees feeling the need to constantly endure the most hardship; (2)Consequences of Hardship-constantly enduring hardships has significant negative effects on wellness; (3)Trainees are Humans-trainees are people with basic human needs, especially the need for worth; (4)Research Time as Refuge-dedicated research time is treated as an oasis away from clinical hardships. Conclusions Perspectives from support persons can offer valuable insight into the wellness needs of surgical trainees. According to support persons, surgical training profoundly negatively impacts trainee wellness. Unlike during clinical training, dedicated research time is a period during which wellness can be prioritized. Programs should provide greater attention to mitigating the negative ramifications of surgical training and promoting wellness in a longitudinal fashion throughout training.

OBJECTIVE To evaluate the association of historical racist housing policies and modern-day healthcare outcomes. SUMMARY OF BACKGROUND DATA In 1933 the United States Government Home Owners Loan Corporation (HOLC) used racial composition of neighborhoods to determine creditworthiness and labeled them "Best", "Still Desirable", "Definitely Declining", and "Hazardous." Although efforts have been made to reverse these racist policies that structurally disadvantage those living in exposed neighborhoods, the lasting legacy on modern day healthcare outcomes is uncertain. METHODS We performed a cross-sectional retrospective review of 212,179 Medicare beneficiaries' living in 171,930 unique neighborhoods historically labeled by the HOLC who underwent 1 of 5 of common surgical procedures - coronary artery bypass, appendectomy, colectomy, cholecystectomy, and hernia repair - between 2012 and 2018. We compared 30-day mortality, complications, and readmissions across HOLC grade and Area Deprivation Index (ADI) of each neighborhood. Outcomes were risk-adjusted using a multivariable logistical regression model accounting for patient factors (age, sex, Elixhauser comorbidities), admission type (elective, urgent, emergency), type of operation, and each neighborhoods ADI; a modern day measure of neighborhood disadvantage that includes education, employment, housing-quality, and poverty measures. RESULTS Overall, 212,179 Medicare beneficiaries (mean age, 71.2 years; 54.2% women) resided in 171,930 unique neighborhoods historically graded by the HOLC. Outcomes worsened in a stepwise fashion across HOLC neighborhoods. Overall, 30-day postoperative mortality was 5.4% in "Best" neighborhoods, 5.8% in "Still Desirable", 6.1% in "Definitely Declining", and 6.4% in "Hazardous" (Best vs Hazardous Odds Ration: 1.23, 95% CI: 1.13-1.24, P < 0.001). The same stepwise pattern was seen from "Best" to "Hazardous" neighborhoods for complications (30.5% vs 32.2%; OR: 1.12 [95% CI: 1.07-1.17]; P < 0.001) and Readmissions (16.3% vs 17.1%; OR: 1.06 [95% CI: 1.01-1.11]; P = 0.023). After controlling for modern day deprivation using ADI, the patterns persisted with "Hazardous" neighborhoods having higher mortality (OR: 1.17 [95% CI: 1.08-1.27]; P < 0.001) and complications (OR: 1.07 [95% CI: 1.02-1.12]; P = 0.003), but not for readmissions (OR: 1.02 [95% CI: 0.97-1.07]; P = 0.546). CONCLUSIONS Patients residing in neighborhoods previously "redlined" or labeled "Hazardous" were more likely to experience worse outcomes after inpatient hospitalization compared to those living in "Best" neighborhoods, even after taking into account modern day measures of neighborhood disadvantage.

Background Variable approaches to intraoperative communication impede our understanding of surgical decision-making and best practices. This is critical among hernia repairs, where improved outcomes are reliant on understanding the impact of different patient characteristics and surgical approaches. In this context, a hernia-specific synoptic operative note was piloted as part of an effort to create a statewide hernia registry. We aimed to understand the impact of the synoptic operative note on variable missingness and evaluate barriers and facilitators to improved intraoperative communication and note adoption. Methods In January 2020, the Michigan Surgical Quality Collaborative (MSQC) registry was expanded to capture hernia-specific intraoperative variables. A synoptic operative note for hernia repair was piloted at 8 hospitals. The primary outcome was change in hernia variable communication, measured by missingness. Using a sequential explanatory mixed-methods design, we performed semi-structured interviews with data abstractors (n = 4) and surgeons (n = 4) at 5 pilot sites to assess barriers and facilitators of implementation. Interviews were iteratively analyzed using content analysis with both deductive and inductive approaches. Results From January to June 2020, 870 hernia repairs were performed across 8 pilot and 53 control sites. Pilot sites had significantly less missingness for all hernia-specific variables. At pilot sites, 46% of notes were fully complete in regard to hernia variables, compared to 21% at control sites (p value

Recent research has raised concern that healthcare segregation, the high concentration of racial groups within a subset of hospitals, is a key contributor to persistent disparities in surgical care. However, to date the extent and effect of hospital level segregation among patients undergoing resection for lung cancer remains unclear.We used 100% Medicare fee-for-service claims to evaluate the degree of hospital level racial segregation for patients undergoing resection for lung cancer between 2014-2018. Hospitals serving high volume of minority patients were defined as the top decile of hospitals by volume of racial and ethnic minority beneficiaries served. Multivariable logistic regression analysis was used compare surgical outcomes between hospitals serving high vs. low volumes of minority patients.A total of 122,943 patients were included with racial composition of 360 (0.3%) American Indian or Native American, 2,077 (1.7%) Asian or Pacific Islander, 1,146(0.9%) Hispanic or Latino, 8,707(7.1%) non-Hispanic Black and 108,665(88.4%) non-Hispanic White. Overall, 31.6%, 15.9%, 15.0% and 7.8% of all hospitals performed 90% of lung cancer resection for Black, Asian, Hispanic, and Native American patients, respectively. Hospitals performing higher volumes of operations for racial and ethnic minorities had higher mortality(3.9% vs. 3.1%; OR 1.19, 95%CI 1.15-1.23; P0.001), complications(18.1% vs. 15.9%; OR 1.17, 95%CI 1.14-1.19; P0.001 and readmissions(11.7% vs. 11.2%; OR 1.04, 95%CI 1.02-1.05; P0.001) for resection for lung cancer.Our findings suggest that a small proportion of hospitals provide a disproportionate amount of surgical care for racial and ethnic minorities with lung cancer with inferior surgical outcomes.

While there is a broad understanding that patient factors, hospital characteristics, and an individual's neighborhoods all contribute to the observed disparities, the relationship between these factors remains unclear. The purpose of this study was to evaluate the association of neighborhood deprivation improve postoperative outcomes for White and Black Medicare beneficiaries equally.We performed a cross-sectional Retrospective cohort study from 2014 to 2018 of 1372,487 White and Black Medicare beneficiaries aged 65 and older who underwent an inpatient colon resection, coronary artery bypass, cholecystectomy, appendectomy, or incisional hernia repair. We compared postoperative complications, readmission, and mortality by race across neighborhood deprivation. Outcomes were risk-adjusted using a multivariable logistical regression model accounting for patient factors (age, sex, Elixhauser comorbidities), admission type (elective, urgent, emergency), type of operation, and each neighborhoods Area Deprivation Index; a modern-day measure of neighborhood disadvantage that includes education, employment, housing quality, and poverty measures.Overall, 1372,487 Medicare beneficiaries with mean age 72.1 years, 50.3% female, 91.2% White, residing in 1107,051 unique neighborhoods underwent 1 of 5 operations. The proportion of Black beneficiaries was 6.5% within the lowest deprivation neighborhoods and increased to 16.9% within the highest deprivation neighborhoods (P0.001). The interaction between beneficiary neighborhood and race demonstrated that the association of neighborhood on outcomes varied by race. Specifically, White beneficiaries had 1.5% absolute mortality decrease from the highest to lowest deprivation neighborhoods [odds ratio (OR):1.32, 95% confidence interval (CI): 1.27-1.38; P0.001], whereas Black beneficiaries had a 0.72% absolute mortality decrease from the highest to lowest deprivation neighborhoods (OR: 1.13, 95% CI: 1.02-1.24; P=0.018). Similarly, White beneficiaries had 3.6% absolute decrease in complication rate from the highest to lowest deprivation neighborhoods (OR: 1.23, 95% CI: 1.21-1.28; P0.001) while Black beneficiaries had a 1.2%% absolute decrease in complication rate from the highest to lowest deprivation neighborhoods (OR: 1.07, 95% CI: 1.01-1.13; P=0.017). For 30-day readmission rates, White beneficiaries realized a 2.3% absolute decrease from the highest to lowest deprivation neighborhoods (OR: 1.19, 95% CI: 1.02-1.24; P0.001), whereas Black beneficiaries saw no change (OR: 1.03, 95% CI: 0.97-1.10; P=0.269).Lower neighborhood deprivation is associated with improved outcomes across both White and Black Medicare beneficiaries; however, improvement in neighborhood deprivation disproportionately favored White beneficiaries. These findings provide a cautionary example of the misperception of the protective effect of higher social class for Black patients and provide a cautionary example that improvements in neighborhoods may have disparate health impact on its members.

Today, many hospitals are part of a multihospital network, which changes the context in which surgeons are asked to lead. This study explores key leadership competencies that surgical leaders use to navigate this hospital network expansion.In this qualitative study, 30 surgical leaders were interviewed. Interviews were coded and analyzed via thematic analysis.We identified three key competencies that leaders felt were important leadership skills to successfully navigate expanding hospital networks. First, leaders must steer the departmental vision within the evolving hospital network landscape. Second, leaders must align the visions of the department and of the hospital network. Third, leaders must build a network-oriented culture within their department.As networks expand, leaders are tasked with unifying vision in their department. Leaders identified a unique opportunity to leverage their growing influence across the hospital network and invested in the people and culture of their department.

Objective To obtain insights into the effects of surgical training on the well-being of support persons. Summary background data Surgical trainee wellness is a critical priority among surgical educators and leaders. The impact of surgical training on the wellness of loved ones who support trainees has not been previously studied. Methods This qualitative study employs semi-structured interviews of 32 support persons of surgical trainees at a single tertiary care center with multiple surgical specialty training programs. Interviews focused on perceptions about supporting a surgical trainee. Transcripts underwent thematic analysis with semantic and conceptual coding. Key themes regarding the effects that caring for a trainee has on support persons are reported. Results Three key themes were identified: (1) Sacrifices-support persons report significant tangible and intangible sacrifices, (2) Delaying life-life is placed on hold to prioritize training, and (3) A disconnect-there is a disconnect and a lack of recognition of support person needs that require greater awareness and targeted interventions. Conclusions The impact of surgical training can extend beyond trainees and can affect the wellness of their support persons who endure the effects of training alongside trainees. Programs should be aware of these effects and develop meaningful strategies to aid trainees and their support persons.

This cohort study evaluates trends in the adoption of robotic surgery among Medicare beneficiaries and privately insured patients for common general surgical procedures.

ImportanceParastomal hernia is a challenging complication following ostomy creation; however, the incidence and long-term outcomes after elective parastomal hernia repair are poorly characterized.ObjectiveTo describe the incidence and long-term outcomes after elective parastomal hernia repair.Design, Setting, and ParticipantsUsing 100% Medicare claims, a retrospective cohort study of adult patients who underwent elective parastomal hernia repair between January 1, 2007, and December 31, 2015, was performed. Logistic regression and Cox proportional hazards models were used to evaluate mortality, complications, readmission, and reoperation after surgery. Analysis took place between February and May 2022.ExposuresParastomal hernia repair without ostomy resiting, parastomal hernia repair with ostomy resiting, and parastomal hernia repair with ostomy reversal.Main Outcomes and MeasuresMortality, complications, and readmission within 30 days of surgery and reoperation for recurrence (parastomal or incisional hernia repair) up to 5 years after surgery.ResultsA total of 17 625 patients underwent elective parastomal hernia repair (mean [SD] age, 73.3 [9.1] years; 10 059 female individuals [57.1%]). Overall, 7315 patients (41.5%) underwent parastomal hernia repair without ostomy resiting, 2744 (15.6%) underwent parastomal hernia repair with ostomy resiting, and 7566 (42.9%) underwent parastomal hernia repair with ostomy reversal. In the 30 days after surgery, 676 patients (3.8%) died, 7088 (40.2%) had a complication, and 1740 (9.9%) were readmitted. The overall adjusted 5-year cumulative incidence of reoperation was 21.1% and was highest for patients who underwent parastomal hernia repair with ostomy resiting (25.3% [95% CI, 25.2%-25.4%]) compared with patients who underwent parastomal hernia repair with ostomy reversal (18.8% [95% CI, 18.7%-18.8%]). Among patients whose ostomy was not reversed, the hazard of repeat parastomal hernia repair was the same for patients whose ostomy was resited vs those whose ostomy was not resited (adjusted hazard ratio, 0.93 [95% CI, 0.81-1.06]).Conclusions and RelevanceIn this study, more than 1 in 5 patients underwent another parastomal or incisional hernia repair within 5 years of surgery. Although this was lowest for patients who underwent ostomy reversal at their index operation, ostomy resiting was not superior to local repair. Understanding the long-term outcomes of this common elective operation may help inform decision-making between patients and surgeons regarding appropriate operative approach and timing of surgery.

OBJECTIVE To evaluate associations between hospital participation in Bundled Payments for Care Improvement (BPCI) and thirty-day total episode and post-acute care spending for lower extremity joint replacement (LEJR), coronary artery bypass graft (CABG), and colectomy. SUMMARY BACKGROUND DATA BPCI has been shown to reduce spending for LEJR episodes only, largely from reductions in post-acute care. However, BPCI efficacy in other common elective procedures, including CABG and colectomy, remains unclear. It is also unknown whether post-acute care spending reductions drive total spending reductions outside of LEJR. METHODS Retrospective cohort study using 100% Medicare claims data to identify BPCI (312 total) and non-BPCI (1,977 total) acute care hospitals from January 1, 2010 to November 30, 2016 with Medicare-enrolled patient discharges for at least one BPCI episode: LEJR (454,369 episodes), CABG (107,307 episodes), or colectomy (73,717 episodes). Along with difference-in-differences analysis, we constructed generalized synthetic controls in the presence of non-parallel trends to estimate associations between BPCI participation and thirty-day total and post-acute care spending. RESULTS Difference-in-differences estimates indicated reduced spending for LEJR (-$541.6 (95% CI: -718.0 to -365.3)) and colectomy (-$582.1 (95% CI: -927.3 to -236.8)) but not CABG (-$268.9 (95% CI: -831.5 to 293.7)). Generalized synthetic control estimates indicated reduced spending for LEJR (-$795.3 (95% CI: -1022.1 to -582.2)) but not colectomy (-$251.3 (95% CI: -997.9 to 335.2)) or CABG (-$257.8 (95% CI: -1024.6 to 414.8)). Post-acute care comprised 42.6% of LEJR spending reductions and 53.0% of colectomy spending reductions. CONCLUSIONS BPCI participation was associated with significant spending reductions for LEJR and colectomy but not CABG. We conclude that BPCI has episode-dependent efficacy, largely determined by post-acute care.

OBJECTIVE To assess risk-adjusted outcomes and participant perceptions following a statewide coaching program for bariatric surgeons. SUMMARY OF BACKGROUND DATA Coaching has emerged as a new approach for improving individual surgeon performance, but lacks evidence linking to clinical outcomes. METHODS This program took place between October 2015 and February 2018 in the Michigan Bariatric Surgery Collaborative. Surgeons were categorized as coach, participant, or nonparticipant for an interrupted time series analysis. Multilevel logistic regression models included patient characteristics, time trends, and number of sessions. Risk-adjusted overall and surgical complication rates are reported, as are within-group relative risk ratios and 95% confidence intervals. We also compared operative times and report risk differences and 95% confidence intervals. Iterative thematic analysis of semi-structured interviews examined participant and coach perceptions of the program. RESULTS The coaching program was viewed favorably by most surgeons and many participants described numerous technical and nontechnical practice changes. The program was not associated with significant change in risk-adjusted complications with relative risks for coaches, participants, and nonparticipants of 0.99 (0.62-1.37), 0.91 (0.64-1.17), and 1.15 (0.83-1.47), respectively. Operative times did improve for participants, but not coaches or nonparticipants, with risk differences of -14.0 (-22.3, -5.7), -1.0 (-4.5, 2.4), and -2.6 (-6.9, 1.7). Future coaching programmatic design should consider dose-complexity matching, hierarchical leveling, and optimizing video review. CONCLUSIONS This statewide surgical coaching program was perceived as valuable and surgeons reported numerous practice changes. Operative times improved, but there was no significant improvement in risk-adjusted outcomes.

OBJECTIVE To determine if initial American Board of Surgery certification in general surgery is associated with better risk-adjusted patient outcomes for Medicare patients undergoing partial colectomy by an early career surgeon. BACKGROUND Board certification is a voluntary commitment to professionalism, continued learning, and delivery of high-quality patient care. Not all surgeons are certified, and some have questioned the value of certification due to limited evidence that board-certified surgeons have better patient outcomes. In response, we examined the outcomes of certified versus noncertified early career general surgeons. METHODS We identified Medicare patients who underwent a partial colectomy between 2008 and 2016 and were operated on by a non-subspecialty trained surgeon within their first 5 years of practice. Surgeon certification status was determined using the American Board of Surgery data. Generalized linear mixed models were used to control for patient-, procedure-, and hospital-level effects. Primary outcomes were the occurrence of severe complications and occurrence of death within 30 days. RESULTS We identified 69,325 patients who underwent a partial colectomy by an early career general surgeon. The adjusted rate of severe complications after partial colectomy by certified (n = 4239) versus noncertified (n = 191) early-career general surgeons was 9.1% versus 10.7% (odds ratio 0.83, P = 0.03). Adjusted mortality rate for certified versus noncertified early-career general surgeons was 4.9% versus 6.1% (odds ratio 0.79, P = 0.01). CONCLUSION Patients undergoing partial colectomy by an early career general surgeon have decreased odds of severe complications and death when their surgeon is board certified.

OBJECTIVE To compare the safety of sleeve gastrectomy and gastric bypass in a large cohort of commercially insured bariatric surgery patients from the IBM MarketScan claims database, while accounting for measurable and unmeasurable sources of selection bias in who is chosen for each operation. SUMMARY OF BACKGROUND DATA Sleeve gastrectomy has rapidly become the most common bariatric operation performed in the United States, but its longer-term safety is poorly described, and the risk of worsening gastroesophageal reflux requiring revision may be higher than previously thought. Prior studies comparing sleeve gastrectomy to gastric bypass are limited by low sample size (in randomized trials) and selection bias (in observational studies). METHODS Instrumental variables analysis of commercially insured patients in the IBM MarketScan claims database from 2011 to 2018. We studied patients undergoing bariatric surgery from 2012 to 2016. We identified re-interventions and complications at 30 days and 2 years from surgery using Comprehensive Procedural Terminology and International Classification of Disease (ICD)-9/10 codes. To overcome unmeasured confounding, we use the prior year's sleeve gastrectomy utilization within each state as an instrumental variable-exploiting variation in the timing of payers' decisions to cover sleeve gastrectomy as a natural experiment. RESULTS Among 38,153 patients who underwent bariatric surgery between 2012 and 2016, the share of sleeve gastrectomy rose from 52.6% (2012) to 75% (2016). At 2 years from surgery, patients undergoing sleeve gastrectomy had fewer re-interventions (sleeve 9.9%, bypass 15.6%, P < 0.001) and complications (sleeve 6.6%, bypass 9.6%, P = 0.001), and lower overall healthcare spending ($47,891 vs $55,213, P = 0.003), than patients undergoing gastric bypass. However, at the 2-year mark, revisions were slightly more common in sleeve gastrectomy than in gastric bypass (sleeve 0.6%, bypass 0.4%, P = 0.009). CONCLUSIONS AND RELEVANCE In a large cohort of commercially insured patients, sleeve gastrectomy had a superior safety profile to gastric bypass up to 2 years from surgery, even when accounting for selection bias. However, the higher risk of revisions in sleeve gastrectomy merits further exploration.

OBJECTIVE To explore challenges and opportunities for surgery departments' academic missions as they become increasingly affiliated with expanding health systems. SUMMARY BACKGROUND DATA Academic medicine is in the midst of unprecedented change. In addition to facing intense competition, narrower margins, and decreased federal funding, medical schools are becoming increasingly involved with large, expanding health systems. The impact of these health system affiliations on surgical departments' academic missions is unknown. METHODS Semistructured interviews with 30 surgical leaders at teaching hospitals affiliated with health systems from August - December 2019. Interviews were transcribed verbatim and coded in an iterative process using MaxQDA software. The topic of challenges and opportunities for the academic mission was an emergent theme, analyzed using thematic analysis. RESULTS Academic health systems typically expanded to support their business goals, rather than their academic mission. Changes in governance sometimes disempowered departmental leadership, shifted traditional compensation models, redirected research programs, and led to cultural conflict. However, at many institutions, health system growth cross-subsidized surgical departments' research and training missions, expanded their clinical footprint, enabled them to improve standards of care, and enhanced opportunities for researchers and trainees. CONCLUSIONS Though health system expansion generally intended to advance business goals, the accompanying academic and clinical opportunities were not always fully captured. Alignment between medical school and health system goals enabled some surgical department leaders to take advantage of their health systems' reach and resources in order to support their academic missions.

Background Approximately 70% of hospitals today are part of larger health systems. Proponents of hospital consolidation tout its potential to reduce health spending and improve outcomes, but to the authors' knowledge the available evidence has suggested that this promise is unrealized. Variations in costs and outcomes within systems may highlight opportunities for collaborative quality improvement and practice standardization. To assess this potential, the authors sought to measure variations in episode spending within and across hospital systems among Medicare beneficiaries undergoing complex cancer surgery. Methods Using 100% Medicare claims data, the authors identified fee-for-service Medicare patients who were undergoing elective pancreatectomy, lung resection, or colectomy for cancer from 2014 through 2016. Risk-adjusted, price-standardized payments for the surgical episode from admission through 30 days after discharge were calculated. The authors then assessed the reliability-adjusted variations at the hospital and system levels. Results Average episode payments varied nearly as much within hospital systems for pancreatectomy ($1946 between the lowest and highest spending systems; 95% CI, $1910-$1972), lung resection ($625 between the lowest and highest spending systems; 95% CI, $621-$630), and colectomy ($813 between the lowest and highest spending systems; 95% CI, $809-$817) as they did between the lowest and highest spending hospitals (pancreatectomy: $2034; lung resection: $1789; and colectomy: $770). For pancreatectomy, this variation was driven by index hospitalization spending whereas both index hospitalization and postacute care use drove variations for lung resection and colectomy. Conclusions In this analysis of Medicare patients undergoing complex cancer surgery, wide variations in surgical episode spending were noted both within and across hospital systems. System leaders may seek to better understand variations in practices among their hospitals to standardize care and reduce variations in outcomes, use, and costs.

Background Telehealth may be an important care delivery modality in reducing dropout from bariatric surgery programs which is reported globally at approximately 50%. Methods In this convergent mixed methods case study of a large, US healthcare system, we examine the impact of telehealth implementation in 2020 on pre-operative bariatric surgery visits and provider perspectives of telehealth use. Results We find that telehealth was significantly associated with a 38% reduction in no-show rate compared with the prior year. Additionally, providers had positive experiences with regard to the appropriateness and feasibility of using telehealth in the pre-operative bariatric surgery process. Conclusions Telehealth use in the pre-operative bariatric surgery process may lead to greater efficiency in healthcare resource utilization. Insurance providers and bariatric accreditation bodies globally should consider accepting telehealth visits and self-reported weights when determining coverage decisions to ensure access for patients.