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Readmissions and emergency department (ED) visits after colorectal surgery (CRS) are common, burdensome, and costly. Effective strategies to reduce these unplanned postdischarge health care visits require a nuanced understanding of how and why patients make the decision to seek care. We used a purposefully stratified sample of 18 interview participants from a prospective cohort of adult CRS patients. Thirteen (72%) participants had an unplanned postdischarge health care visit. Participant decision-making was classified by methodology (algorithmic, guided, or impulsive), preexisting rationale, and emotional response to perceived health care needs. Participants voiced clear mental algorithms about when to visit an ED. In addition, participants identified facilitators and barriers to optimal health care use. They also identified tangible targets for health care utilization reduction efforts, such as improved care coordination with streamlined discharge instructions and improved communication with the surgical team. Efforts should be directed at improving postdischarge communication and care coordination to reduce CRS patients’ high-resource health care utilization.

Background Fatigue after thyroidectomy is common, but there is a paucity of data regarding its prevalence and duration. We hypothesized that total thyroidectomy (TT) patients would have more long-term fatigue than thyroid lobectomy (TL) patients. Methods Statewide survey of thyroidectomy patients (2004-2017) was carried out. Results 281 patients completed the survey. 216 respondents (77%) had TT and 65 (23%) had TL. Within one year of surgery, 172 (61%) respondents recalled being troubled by new fatigue all, most, or some of the time. Total thyroidectomy patients were more likely to report new fatigue (69% vs. 44%, aOR 2.72, 95% CI 1.44 to 5.18). Of patients ( n = 172) reporting new fatigue, 67 (39%) reported at least moderate improvement. Nineteen (28%) saw improvement within 1 year, 35 (52%) saw improvement in 1-2 years, and 11 (16%) saw improvement after 2 years. Conclusion Long-term fatigue after TT can be debilitating, long-lasting, and less prevalent after TL.

Background Adult colorectal surgery patients continue to have high rates of readmissions, despite known risk factors for non-routine postdischarge care (emergency department (ED) visit or rehospitalization) and countless interventions to address these. It is unclear how the difficult-to-quantify patient perspective frames and modifies the impact of these quantifiable risk factors. Study design We identified consecutive adult inpatient colorectal surgery patients from 2017 to 2018. This mixed methods study merged data from electronic health records and in-depth patient interviews. Results We enrolled 258 participants, surveyed 167, and interviewed 18. Depressive symptoms represent one of many risk factors confirmed to increase non-routine healthcare utilization (RR 1.85, 95% CI 1.02–3.37), though the patient perspective explained why these symptoms seemed to greatly impact some patients more than others. Additionally, consistent with patient report, patients with non-routine postdischarge care (26%) were less likely to report communication with their surgical team (80% vs 97%, p Conclusion Patient perspectives add depth and understanding of the impact of risk factors on non-routine post-discharge care. This expanded knowledge explains why one patient is more likely to visit an ED close to home whereas another patient might prefer to visit their surgeon’s clinic directly. Effective strategies to reduce unplanned postdischarge care should be tailored.

Thirty-day readmissions, emergency department visits, and observation stays are common after colorectal surgery (9%-25%, 8%-12%, and 3%-5%), yet it is unknown to what extent planned postdischarge care can decrease the frequency of emergency department visits.This study's aim was to determine whether early follow-up with the surgical team reduces 30-day emergency department visits.This retrospective cohort study used a central data repository of clinical and administrative data for 2013 through 2018.This study was conducted in a large statewide health care system (10 affiliated hospitals,300 practices).All adult patients undergoing colorectal surgery were included unless they had a length of stay1 day or died during the index hospitalization.Early (10 days after discharge) versus late (≥10 days) follow-up at the outpatient surgery clinic, or no outpatient surgery clinic follow-up, was assessed.The primary outcome measured was the time to 30-day postdischarge emergency department visit.Our cohort included 3442 patients undergoing colorectal surgery; 38% of patients had an early clinic visit. Overall, 11% had an emergency department encounter between 11 and 30 days after discharge. Those with early follow-up had decreased emergency department encounters (adjusted HR 0.13; 95% CI, 0.08-0.22). An early clinic visit within 10 days, compared to 14 days, prevented an additional 142 emergency department encounters. Nationwide, this could potentially prevent 8433 unplanned visits each year with an estimated cost savings of $49 million annually.We used retrospective data and were unable to assess for health care utilization outside our health system.Early follow-up within 10 days of adult colorectal surgery is associated with decreased subsequent emergency department encounters. See Video Abstract at http://links.lww.com/DCR/B330. EL SEGUIMIENTO TEMPRANO DESPUÉS DE LA CIRUGÍA COLORRECTAL REDUCE LAS VISITAS AL SERVICIO DE URGENCIAS POSTERIOR AL ALTA: Los readmisión a los treinta días, las visitas al servicio de urgencias y las estancias de observación son comunes después de la cirugía colorrectal, 9-25%, 8-12% y 3-5%, respectivamente. Sin embargo, se desconoce en qué medida la atención planificada posterior al alta puede disminuir la frecuencia de las visitas al servicio de urgencias.Determinar si el seguimiento temprano con el equipo quirúrgico reduce las visitas a 30 días al servicio de urgencias.Este estudio de cohorte retrospectivo utilizó un depósito central de datos clínicos y administrativos para 2013-2018.Gran sistema de salud estatal (10 hospitales afiliados,300 consultorios).Se incluyeron todos los pacientes adultos de cirugía colorrectal a menos que tuvieran una estadía1 día o murieran durante el índice de hospitalización.Temprano (10 días después del alta) versus tardío (≥10 días) o sin seguimiento en la clínica de cirugía ambulatoria.Tiempo para la visita al servicio de urgencias a 30 días después del alta.Nuestra cohorte incluyó 3.442 pacientes de cirugía colorrectal; El 38% de los pacientes tuvieron una visita temprana a clínica. En total, el 11% tuvo un encuentro con el servicio de urgencias entre 11 y 30 días después de ser dado de alta. Aquellos con seguimiento temprano disminuyeron las visitas al servicio de urgencias (HR 0,13; IC del 95%: 0,08 a 0,22). Además, una visita temprana a la clínica en un plazo de 10 días, en comparación con 14 días, evitó 142 encuentros adicionales en el servicio de urgencias. A nivel nacional, esto podría prevenir 8.433 visitas no planificadas cada año con un ahorro estimado de $ 49 millones anuales.Utilizamos datos retrospectivos y no pudimos evaluar la utilización de la atención médica fuera de nuestro sistema de salud.El seguimiento temprano dentro de los 10 días de la cirugía colorrectal en adultos se asocia con una disminución de los encuentros posteriores en el servicio de urgencias. Consulte Video Resumen en http://links.lww.com/DCR/B330. (Traducción-Dr. Gonzalo Hagerman).

It is unknown if opioid naïve patients who undergo minimally invasive, benign foregut operations are at risk for progressing to persistent postoperative opioid use. The purpose of our study was to determine if opioid naïve patients who undergo minimally invasive, benign foregut operations progress to persistent postoperative opioid use and to identify any patient- and surgery-specific factors associated with persistent postoperative opioid use.Opioid-naïve, adult patients who underwent laparoscopic fundoplication, hiatal hernia repair, or Heller myotomy from 2010 to 2018 were identified within the IBM® MarketScan® Commercial Claims and Encounters Database. Daily drug logs of the preoperative and postoperative period were evaluated to assess for changes in drug use patters. The primary outcome of interest was persistent postoperative opioid use, defined as at least 33% of the proportion of days covered by opioid prescriptions at 365-day follow-up. Patient demographic information and clinical risk factors for persistent postoperative opioid use at 365 days postoperatively were estimated using log-binomial regression.A total of 17,530 patients met inclusion criteria; 6895 underwent fundoplication, 9235 underwent hiatal hernia repair, and 1400 underwent Heller myotomy. 9652 patients had at least one opioid prescription filled in the perioperative period. Sixty-five patients (0.4%) were found to have persistent postoperative opioid use at 365 days postoperatively. Lower Charlson comorbidity index scores and a history of mental illness or substance use disorder had a statistically but not clinically significant protective effect on the risk of persistent postoperative opioid use at 365 days postoperatively.Only half of opioid naïve patients undergoing minimally invasive, benign foregut operations filled an opioid prescription postoperatively. The risk of progression to persistent postoperative opioid use was less than 1%. These findings support the current guidelines that limit the number of opioid pills prescribed following general surgery operations.

Background In 1993, the Family and Medical Leave Act (FMLA) mandated 12 weeks of unpaid, job-protected leave. The current impact of taking 12 weeks of leave during residency has not been evaluated. Methods We examined the 2018 Accreditation Council for Graduate Medical Education (n = 24) specialty leave policies to determine the impact of 6- and 12-week leave on residency training, board eligibility, and fellowship training. We compared our findings with a 2006 study. Results In 2018, five (21%) specialties had policy language regarding parental leave during residency, and four (16%) had language regarding medical leave. Median leave allowed was 4 weeks (IQR 4-6). Six specialties (25%) decreased the number of weeks allowed for leave from 2006 to 2018. In 2006, a 6-week leave would cause a 1-year delay in board eligibility in six specialties; in 2018, it would not cause delayed board eligibility in any specialty. In 2018, a 12-week (FMLA) leave would extend training by a median of 6 weeks (mean 4.1, range 0-8), would delay board eligibility by 6-12 months in three programs (mean 2.25, range 0-12), and would delay fellowship training by at least 1 year in 17 specialties (71%). The impact of a 12-week leave was similar between medical and surgical specialties. Conclusions While leave policies have improved since 2006, most specialties allow for 6 weeks of leave, less than half of what is mandated by the FMLA. Moreover, a 12-week, FMLA-mandated leave would cause significant delays in board certification and entry into fellowship for most residency programs.

Background Rates of readmission after colorectal surgery (CRS) range from 9% to 25% and cost the US $300 million annually. The aim of this study was to identify risk factors for 30-d readmission after CRS. Our hypothesis was that transfer from an outside hospital before CRS increases incidence of 30-d readmission. Methods Using the Healthcare Cost and Utilization Project Nationwide Readmissions Database, a retrospective analysis of surviving adult patients who underwent inpatient colon and/or rectal resection from 2010 to 2014 was performed. Using multivariable logistic regression, we assessed the direct effect of potential risk factors for readmission, including demographics, hospital characteristics, comorbidities, indication for CRS, and transfer status to the index hospital where the CRS was performed. Results A total of 336,792 patients were included, and 13% (n = 43,546) were readmitted within 30 d. Overall, 1% of patients (n = 3652) were transferred from another hospital for surgery, and these patients were more likely to be older, have comorbidities, have public insurance, and have low income. After adjustment, age, insurance type, household income, comorbidities, and primary indication for CRS were all significant predictors of readmission. Transfer status did not meaningfully impact the incidence of readmission after accounting for patient and hospital characteristics (aOR 1.08, 95% CI 1.00, 1.18). Patients with primary indications of trauma (aOR 1.88, 95% CI 1.48, 2.38), inflammatory bowel disease (aOR 1.64, 95% CI 1.1.56, 1.71), and ischemia (aOR 1.77, 95% CI 1.1.59, 1.97) were most likely to be readmitted. Patients treated at a rural nonteaching hospital, compared with those at a urban teaching hospital, were significantly less likely to be readmitted (aOR 0.80, 95% CI 0.76, 0.83). Conclusions Preoperative factors, such as patient comorbidities and primary indications for CRS, are important risk factors for postoperative readmission. Although transfer status does not independently predict readmission, it serves as a proxy for a high-risk group of patients that could be targeted for future interventions.

IMPORTANCE: Factors contributing to underrepresentation of women in surgery are incompletely understood. Pro-male bias and stereotype threat appear to contribute to gender imbalance in surgery. OBJECTIVES: To evaluate the association between pro-male gender bias and career engagement and the effect of stereotype threat on skill performance among trainees in academic surgery. DESIGN, SETTING, AND PARTICIPANTS: A 2-phase study with a double-blind, randomized clinical trial component was conducted in 3 academic general surgery training programs. Residents were recruited between August 1 and August 15, 2018, and the study was completed at the end of that academic year. In phase 1, surveys administered 5 to 6 months apart investigated the association of gender bias with career engagement. In phase 2, residents were randomized 1:1 using permuted-block design stratified by site, training level, and gender to receive either a trigger of or protection against stereotype threat. Immediately after the interventions, residents completed the Fundamentals of Laparoscopic Surgery (FLS) assessment followed by a final survey. A total of 131 general surgery residents were recruited; of these 96 individuals with academic career interests met eligibility criteria; 86 residents completed phase 1. Eighty-five residents were randomized in phase 2, and 4 residents in each arm were lost to follow-up. INTERVENTION: Residents read abstracts that either reported that women had worse laparoscopic skill performance than men (trigger of stereotype threat [A]) or had no difference in performance (protection against stereotype threat [B]). MAIN OUTCOMES AND MEASURES: Association between perception of pro-male gender bias and career engagement survey scores (phase 1) and stereotype threat intervention and FLS scores (phase 2) were the outcomes. Intention-to-treat analysis was conducted. RESULTS: Seventy-seven residents (38 women [49.4%]) completed both phases of the study. The association between pro-male gender bias and career engagement differed by gender (interaction coefficient, −1.19; 95% CI, −1.90 to −0.49; P = .02); higher perception of bias was associated with higher engagement among men (coefficient, 1.02; 95% CI, 0.19-2.24; P = .04), but no significant association was observed among women (coefficient, −0.25; 95% CI, −1.59 to 1.08; P = .50). There was no evidence of a difference in FLS score between interventions (mean [SD], A: 395 [150] vs B: 367 [157]; P = .51). The response to stereotype threat activation was similar in men and women (interaction coefficient, 15.1; 95% CI, −124.5 to 154.7; P = .39). The association between stereotype threat activation and FLS score differed by gender across levels of susceptibility to stereotype threat (interaction coefficient, −35.3; 95% CI, −47.0 to −23.6; P = .006). Higher susceptibility to stereotype threat was associated with lower FLS scores among women who received a stereotype threat trigger (coefficient, −43.4; 95% CI, −48.0 to −38.9; P = .001). CONCLUSIONS AND RELEVANCE: Perception of pro-male bias and gender stereotypes may influence career engagement and skill performance, respectively, among surgical trainees. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03623009

Background: Adult colorectal surgery patients continue to have high rates of readmissions, despite known risk factors for non-routine postdischarge care (emergency department (ED) visit or rehospitalization) and countless interventions to address these. It is unclear how the patient perspective frames and modifies the impact of these risk factors. This study aimed to explain why individual risk-factors led a patient to seek non-routine postdischarge care. Methods: This single institution prospective cohort study identified consecutive adult inpatient colorectal surgery patients from 2017-2018. We used a convergent parallel design to integrate electronic health record data with brief phone surveys and in-depth interviews to generate a “what, why, and so what” summary of findings. Findings: We enrolled 258 participants, surveyed 167, and interviewed 18. Overall, 20% were readmitted, 3% had an ED visit, 2% had an observation stay, and 75% had routine postdischarge care. Undergoing open surgery (RR 2.25, 95% CI 1.31-3.87) and reporting depressive symptoms (RR 1.85, 95% CI 1.02-3.37) were associated with an increased non-routine healthcare utilization. Whereas, each 10 miles increasing travel distance (RR 0.94, 95% CI 0.90-0.98), private insurance (RR 0.61 , 95% CI 0.40-0.93), and proactively scheduled follow-up appointments (RR 0.43, 95% CI 0.27-0.69) were protective factors. Patients with non-routine postdischarge care (26%) were less likely to report communication with their surgical team (80% vs 97%, p

Background Streamlined discharge communication in transitions of care improvement models improve patient satisfaction, improve patient self-efficacy, and reduce readmissions. Yet, significant variability and quality exists in the After Visit Summary (AVS) which is used to guide the post-discharge needs of the patient. Objectives We sought assess the feasibility, fidelity, acceptability, and effectiveness of a standardized, patient-centered AVS. Methods Our multiprofessional and multidisciplinary stakeholder team was led by two physicians and had significant institutional support. We employed a tailored, hybrid implementation strategy, blending components from Lean methodology, the Institute for Healthcare Model for Improvement, and the Consolidated Framework for Implementation Research. We assessed the feasibility (e.g. quality of AVS, usability of template), fidelity (e.g. template utilization rates), acceptability (e.g. direct stakeholder feedback, paging-system audit, patient call logs), and effectiveness (e.g. 30-day readmission rates and patient-centeredness) of our intervention (e.g. standardized, patient-centered AVS). Results Our AVS template was written at a third grade reading level but retained all clinically-relevant information. Providers and patients approved of the template with 66% mean utilization (range 41% to 80%). After our intervention, we observed decreased 30-day readmissions (19.7% to 16.0%). Notably, after the introduction of AVS template, pages sent decreased by 3.67 pages weekly (95% CI=[−15.7, 14.0]), but this estimate was imprecise. Conclusions Reducing variability and improving the quality of discharge communication, not only improves patient outcomes, but may also improve workflow for providers. These improved team dynamics are important to assess when considering an intervention that is operationalized by time and resource deprived employees.

A healthy 65-year-old woman presents to the emergency room with a 12-hour history of sudden onset severe lower abdominal pain. This is her first episode. She reports nausea, vomiting, and anorexia. Her last colonoscopy was at age 60, and was normal, except for diverticulosis of the sigmoid colon. Physical examination is significant for fever, tachycardia, and generalized abdominal pain with rebound tenderness. Pertinent laboratory findings include a leukocytosis and metabolic acidosis. A computed tomography (CT) scan is obtained and is consistent with freely perforated diverticulitis, including a thickened sigmoid colon, free fluid in the pelvis and free air noted near the diaphragm (Figure 1). The surgeon completes the patient evaluation, recommends initiation of IV fluid resuscitation and antibiotics, and plans to go immediately to the operating room for surgical resection.

Limited data exist comparing robotic and open approaches to pancreaticoduodenectomy (PD). We performed a multicenter comparison of perioperative outcomes of robotic PD (RPD) and open PD (OPD).Perioperative data for patients who underwent postlearning curve PD at 8 centers (8/2011-1/2015) were assessed. Univariate analyses of clinicopathologic and treatment factors were performed, and multivariable models were constructed to determine associations of operative approach (RPD or OPD) with perioperative outcomes.Of the 1028 patients, 211 (20.5%) underwent RPD (4.7% conversions) and 817 (79.5%) underwent OPD. As compared with OPD, RPD patients had higher body mass index, rates of prior abdominal surgery, and softer pancreatic remnants, whereas OPD patients had a higher percentage of pancreatic ductal adenocarcinoma cases, and greater proportion of nondilated (3 mm) pancreatic ducts. On multivariable analysis, as compared with OPD, RPD was associated with longer operative times [mean difference = 75.4 minutes, 95% confidence interval (CI) 17.5-133.3, P = 0.01], reduced blood loss (mean difference = -181 mL, 95% CI -355-(-7.7), P = 0.04) and reductions in major complications (odds ratio = 0.64, 95% CI 0.47-0.85, P = 0.003). No associations were demonstrated between operative approach and 90-day mortality, clinically relevant postoperative pancreatic fistula and wound infection, length of stay, or 90-day readmission. In the subset of 522 (51%) pancreatic ductal adenocarcinomas, operative approach was not a significant independent predictor of margin status or suboptimal lymphadenectomy (12 lymph nodes harvested).Postlearning curve RPD can be performed with similar perioperative outcomes achieved with OPD. Further studies of cost, quality of life, and long-term oncologic outcomes are needed.

This article begins by introducing the historical background surrounding the volume-outcomes relationship literature, particularly in complex cancer surgery. The state of evidence surrounding mortality, as well as other outcomes, in relation to both hospital and surgeon procedure volume is synthesized. Where it is understood, the level of adoption of regionalization of various complex surgeries in the United States is also presented. Various controversies are weighed and discussed. Finally, various models of regionalization and proposed alternatives to regionalization from the peer-reviewed literature are presented.

This article was migrated. The article was marked as recommended. The surgical discharge summary allows the perioperative care team to summarize a recent hospitalization and relay important information to a variety of invested parties including other healthcare providers, outpatient caregivers, and the surgical patient. The inpatient care team can promote a smooth transition of care and empower outpatient providers and the patient to foster a confident progression through recovery. We describe twelve tips for a streamlined, successful discharge summary geared towards the surgical intern. A successful surgical discharge summary begins with patient and caregiver collaboration, communication and teamwork, and culminates with concise documentation. These tips reflect a review of the current literature and rely on the clinical expertise of an interdisciplinary surgical team. Our aim is to empower surgical educators and trainees to understand the complexity of discharge planning, and to improve the efficiency with which it can be completed and the quality of the discharge process at their training hospitals.

Patient satisfaction is often measured using the Hospital Consumer Assessment of Healthcare Providers and Systems survey. Our aim was to examine the structural and clinical determinants of satisfaction among inpatients with prolonged lengths of stays (LOS).Adult patients who were admitted between 2009 and 2012, had a LOS of 21 days or more, and completed the Hospital Consumer Assessment of Healthcare Providers and Systems survey, were included. Univariate analyses assessed the relationship between satisfaction and patient/system variables. Recursive partitioning was used to examine the relative importance of the identified variables.One hundred one patients met inclusion criteria. The average LOS was 35 days and 58% were admitted to a surgical service. Satisfaction with physician communication was significantly associated with fewer consultations (P.01), nonoperative admission (P.001), no intensive care unit stay (P.01), nonsurgical service (P.01), and non-emergency room admissions (P = .03). Among these, having fewer consultations had the highest relative importance.In long stay patients, having fewer inpatient consultations was the strongest predictor of patient satisfaction with physician communication. This suggests that examination of patient-level data in clinically relevant subgroups may be a useful way to identify targets for quality improvement.