Browsing by Author "Bilimoria, Karl Y."
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Item A Mixed-Methods Evaluation of Clinician Education Modules on Reducing Surgical Opioid Prescribing(Elsevier, 2021) Shallcross, Meagan L.; Stulberg, Jonah J.; Schäfer, Willemijn L. A.; Buckley, Barbara A.; Huang, Reiping; Bilimoria, Karl Y.; Johnson, Julie K.; Surgery, School of MedicineBackground: In this study, we developed online interactive clinician education modules highlighting best practices to minimize opioid prescribing at discharge after surgery. The modules were implemented as part of a multicomponent quality improvement initiative across a six-hospital health system. This article describes the development and evaluation of this educational intervention. Materials and methods: Clinician education modules targeting surgical prescribers, nurses, and pharmacists were developed and implemented by an interdisciplinary team. Clinicians were invited to participate in an evaluation survey after completing the modules. Survey items assessed clinicians' rating of the module and intention to change clinical practice because of the module. Quantitative and qualitative survey responses were analyzed by the study team. Results: A total of 2119 clinicians completed the module and 1831 of these clinicians (86.4%) completed the survey. Of clinicians completing the survey, 65.6% reported that they intend to change clinical practice after completing the module. Intended changes were related to increased knowledge and awareness, provider empowerment, opioid prescribing practices, nonopioid prescribing practices, and patient education. Many clinicians who indicated they do not intend to change practice reported that their clinical practices were already in line with module recommendations. Some clinicians did not perceive the module to be relevant to their role. Conclusions: Module completion was associated with the intention to improve clinical practice in areas related to provider empowerment, opioid prescribing, nonopioid prescribing, and patient education. Evaluation data will inform future module improvements. There is an opportunity to ensure that all clinicians, including those who are not prescribers, recognize their role in opioid stewardship.Item A National Comparison of Operative Outcomes of New and Experienced Surgeons(Wolters Kluwer, 2021) Kelz, Rachel R.; Sellers, Morgan M.; Niknam, Bijan A.; Sharpe, James E.; Rosenbaum, Paul R.; Hill, Alexander S.; Zhou, Hong; Hochman, Lauren L.; Bilimoria, Karl Y.; Itani, Kamal; Romano, Patrick S.; Silber, Jeffrey H.; Surgery, School of MedicineObjective: To determine whether outcomes achieved by new surgeons are attributable to inexperience or to differences in the context in which care is delivered and patient complexity. Background: Although prior studies suggest that new surgeon outcomes are worse than those of experienced surgeons, factors that underlie these phenomena are poorly understood. Methods: A nationwide observational tapered matching study of outcomes of Medicare patients treated by new and experienced surgeons in 1221 US hospitals (2009-2013). The primary outcome studied is 30-day mortality. Secondary outcomes were examined. Results: In total, 694,165 patients treated by 8503 experienced surgeons were matched to 68,036 patients treated by 2119 new surgeons working in the same hospitals. New surgeons' patients were older (25.8% aged ≥85 vs 16.3%,P<0.0001) with more emergency admissions (53.9% vs 25.8%,P<0.0001) than experienced surgeons' patients. Patients of new surgeons had a significantly higher baseline 30-day mortality rate compared with patients of experienced surgeons (6.2% vs 4.5%,P<0.0001;OR 1.42 (1.33, 1.52)). The difference remained significant after matching the types of operations performed (6.2% vs 5.1%, P<0.0001; OR 1.24 (1.16, 1.32)) and after further matching on a combination of operation type and emergency admission status (6.2% vs 5.6%, P=0.0007; OR 1.12 (1.05, 1.19)). After matching on operation type, emergency admission status, and patient complexity, the difference between new and experienced surgeons' patients' 30-day mortality became indistinguishable (6.2% vs 5.9%,P=0.2391;OR 1.06 (0.97, 1.16)). Conclusions: Among Medicare beneficiaries, the majority of the differences in outcomes between new and experienced surgeons are related to the context in which care is delivered and patient complexity rather than new surgeon inexperience.Item A National Mixed-Methods Evaluation of General Surgery Residency Program Responsiveness and the Association with Resident Wellness(Elsevier, 2022) Joung, Rachel H.; Amortegui, Daniela; Silver, Casey M.; Mackiewicz, Natalia I.; Eng, Joshua S.; Rosenkranz, Kari M.; Johnson, Julie; Bilimoria, Karl Y.; Hu, Yue-Yung; Surgery, School of MedicineIntroduction: Resident burnout is highly prevalent in general surgery. Burnout is increasingly recognized as a symptom of an unsupportive workplace. The objectives of this study were to describe resident perceptions of program responsiveness and to identify associated factors. Methods: We used a convergent mixed-methods design. A cross-sectional survey was administered to all U.S. general surgery residents following the 2020 ABSITE, querying resident perceptions of their learning environment (including program responsiveness), burnout, thoughts of attrition and suicide, and career satisfaction. Multivariable logistic regression models adjusting for program/resident characteristics assessed associations of program responsiveness with aspects of the learning environment and resident wellness. 366 interviews and 27 focus groups with residents and faculty were conducted during in-person visits to 15 residency programs. Transcripts were analyzed thematically using inductive and deductive logics until thematic saturation was achieved. Results: Of the 7233 clinically active residents from 323 programs who completed the survey (85.5% response rate), 5256 had data available for all outcomes of interest. 72.1% (n = 3791) reported satisfaction with program responsiveness. These residents were significantly less likely to report 80-hour workweek violations (odds ratio [OR] 0.22, 95% confidence interval [CI] 0.18-0.26), burnout (OR 0.47, 95% CI 0.41-0.53), thoughts of attrition (OR 0.32, 95% CI 0.27-0.38), and suicidality (OR 0.52, 95% CI 0.41-0.65). They were significantly more likely to report satisfaction with career choice, personal life, and work-life balance (all p < 0.001). Factors associated with improved perception of program responsiveness included larger program size (50+ vs. <23 residents; OR 1.48, 95% CI 1.01-2.19), having faculty mentorship (OR 2.64, 95% CI 2.22-3.14), having meaningful input into call and vacation schedules (OR 3.31, 95% CI 2.74-4.00), and feeling comfortable speaking up (OR 4.20, 95% CI 3.47-5.09). We conducted a qualitative analysis to identify the following components of program responsiveness: (1) core values reflecting a shared understanding of the importance of resident voice in shaping the training experience and the program, including mutual trust and respect between residents and faculty, transparency and communication, resident unity, and resident participation in and ownership of program improvement; (2) structural constructs that reflect and support responsiveness; (3) mechanisms for supporting resident agency, including resources and leadership support, faculty advocacy, and resident leadership opportunities. Conclusion: Program responsiveness in surgical residency is associated with improved resident wellness. Programs should develop formal channels to elicit and concretely address resident concerns, provide opportunities for resident representation, and entrust residents with the flexibility and autonomy to make decisions that support their own education and wellness.Item A National Quality Improvement Study Identifying and Addressing Cancer Screening Deficits Due To the COVID-19 Pandemic(Wiley, 2022) Joung, Rachel Hae-Soo; Nelson, Heidi; Mullett, Timothy W.; Kurtzman, Scott H.; Shafir, Sarah; Harris, James B.; Yao, Katharine A.; Brajcich, Brian C.; Bilimoria, Karl Y.; Cance, William G.; Surgery, School of MedicineBackground: Cancer-related deaths over the next decade are expected to increase due to cancer screening deficits associated with the coronavirus disease 2019 (COVID-19) pandemic. Although national deficits have been quantified, a structured response to identifying and addressing local deficits has not been widely available. The objectives of this report are to share preliminary data on monthly screening deficits in breast, colorectal, lung, and cervical cancers across diverse settings and to provide online materials from a national quality improvement (QI) study to help other institutions to address local screening deficits. Methods: This prospective, national QI study on Return-to-Screening enrolled 748 accredited cancer programs in the United States from April through June 2021. Local prepandemic and pandemic monthly screening test volumes (MTVs) were used to calculate the relative percent change in MTV to describe the monthly screening gap. Results: The majority of facilities reported monthly screening deficits (colorectal cancer, 80.6% [n = 104/129]; cervical cancer, 69.0% [n = 20/29]; breast cancer, 55.3% [n = 241/436]; lung cancer, 44.6% [n = 98/220]). Overall, the median relative percent change in MTV ranged from -17.7% for colorectal cancer (interquartile range [IQR], -33.6% to -2.8%), -6.8% for cervical cancer (IQR, -29.4% to 1.7%), -1.6% for breast cancer (IQR, -9.6% to 7.0%), and 1.2% for lung cancer (IQR, -16.9% to 19.0%). Geographic differences were not observed. There were statistically significant differences in the percent change in MTV between institution types for colorectal cancer screening (P = .02). Conclusion: Cancer screening is still in need of urgent attention, and the screening resources made available online may help facilities to close critical gaps and address screenings missed in 2020. Lay summary: Question: How can the effects of the coronavirus disease 2019 pandemic on cancer screening be mitigated? Findings: When national resources were provided, including methods to calculate local screening deficits, 748 cancer programs promptly enrolled in a national Return-to-Screening study, and the majority identified local screening deficits, most notably in colorectal cancer. Using these results, 814 quality improvement projects were initiated with the potential to add 70,000 screening tests in 2021. Meaning: Cancer screening is still in need of urgent attention, and the online resources that we provide may help to close critical screening deficits.Item A National Survey of Motor Vehicle Crashes Among General Surgery Residents(Wolters Kluwer, 2021) Schlick, Cary Jo R.; Hewitt, Daniel Brock; Quinn, Christopher M.; Ellis, Ryan J.; Shapiro, Katherine E.; Jones, Andrew; Bilimoria, Karl Y.; Yang, Anthony D.; Surgery, School of MedicineObjectives: Evaluate the frequency of self-reported, post-call hazardous driving events in a national cohort of general surgery residents and determine the associations between duty hour policy violations, psychiatric well-being, and hazardous driving events. Summary of background data: MVCs are a leading cause of resident mortality. Extended work shifts and poor psychiatric well-being are risk factors for MVCs, placing general surgery residents at risk. Methods: General surgery residents from US programs were surveyed after the 2017 American Board of Surgery In-Training Examination. Outcomes included self-reported nodding off while driving, near-miss MVCs, and MVCs. Group-adjusted cluster Chi-square and hierarchical regression models with program-level intercepts measured associations between resident- and program-level factors and outcomes. Results: Among 7391 general surgery residents from 260 programs (response rate 99.3%), 34.7% reported nodding off while driving, 26.6% a near-miss MVC, and 5.0% an MVC over the preceding 6 months. More frequent 80-hour rule violations were associated with all hazardous driving events: nodding off while driving {59.8% with ≥5 months with violations vs 27.2% with 0, adjusted odds ratio (AOR) 2.86 [95% confidence interval (CI) 2.21-3.69]}, near-miss MVCs, [53.6% vs 19.2%, AOR 3.28 (95% CI 2.53-4.24)], and MVCs [14.0% vs 3.5%, AOR 2.46 (95% CI 1.65-3.67)]. Similarly, poor psychiatric well-being was associated with all 3 outcomes [eg, 8.0% with poor psychiatric well-being reported MVCs vs 2.6% without, odds ratio 2.55 (95% CI 2.00-3.24)]. Conclusions: Hazardous driving events are prevalent among general surgery residents and associated with frequent duty hour violations and poor psychiatric well-being. Greater adherence to duty hour standards and efforts to improve well-being may improve driving safety.Item A postdischarge venous thromboembolism risk calculator for inflammatory bowel disease surgery(Elsevier, 2021) Schlick, Cary Jo R.; Yuce, Tarik K.; Yang, Anthony D.; McGee, Michael F.; Bentrem, David J.; Bilimoria, Karl Y.; Merkow, Ryan P.; Surgery, School of MedicineBackground: Guidelines recommend extended chemoprophylaxis for venous thromboembolism in high-risk patients having operations for inflammatory bowel disease. Quantifying patients' risk of venous thromboembolism, however, remains challenging. We sought (1) to identify factors associated with postdischarge venous thromboembolism in patients undergoing colorectal resection for inflammatory bowel disease and (2) to develop a postdischarge venous thromboembolism risk calculator to guide prescribing of extended chemoprophylaxis. Methods: Patients who underwent an operation for inflammatory bowel disease from 2012 to 2018 were identified from the American College of Surgeons National Surgical Quality Improvement Program for colectomy and proctectomy procedure targeted modules. Postdischarge venous thromboembolism included pulmonary embolism or deep vein thrombosis diagnosed after discharge from the index hospitalization. Multivariable logistic regression estimated the association of patient/operative factors with postdischarge venous thromboembolism. A postdischarge venous thromboembolism risk calculator was subsequently constructed. Results: Of 18,990 patients, 199 (1.1%) developed a postdischarge venous thromboembolism within the first 30 postoperative days. Preoperative factors associated with postdischarge venous thromboembolism included body mass index (1.9% with body mass index ≥35 vs 0.8% with body mass index 18.5-24.9; odds ratio 2.34 [95% confidence interval 1.49-3.67]), steroid use (1.3% vs 0.7%; odds ratio 1.91 [95% confidence interval 1.37-2.66]), and ulcerative colitis (1.5% vs 0.8% with Crohn's disease; odds ratio 1.76 [95% confidence interval 1.32-2.34]). Minimally invasive surgery was associated with postdischarge venous thromboembolism (1.2% vs 0.9% with open; odds ratio 1.42 [95% confidence interval 1.05-1.92]), as was anastomotic leak (2.8% vs 1.0%; odds ratio 2.24 [95% confidence interval 1.31-3.83]) and ileus (2.1% vs 0.9%; odds ratio 2.60 [95% confidence interval 1.91-3.54]). The predicted probability of postdischarge venous thromboembolism ranged from 0.2% to 14.3% based on individual risk factors. Conclusion: Preoperative, intraoperative, and postoperative factors are associated with postdischarge venous thromboembolism after an operation for inflammatory bowel disease. A postdischarge venous thromboembolism risk calculator was developed which can be used to tailor extended venous thromboembolism chemoprophylaxis by individual risk.Item An Evaluation of Peer-Rated Surgical Skill and its Relationship With Detrusor Muscle Sampling in Transurethral Resection of Bladder Tumor(Elsevier, 2022) Pham, Minh N.; Ko, Oliver S.; Huang, Reiping; Vo, Amanda X.; Tsai, Kyle P.; Lai, Jeremy D.; Hudnall, Matthew T.; Halpern, Joshua A.; Meeks, Joshua J.; Benson, Jonas; Soares, Ricardo; Kim, Ronald; Bilimoria, Karl Y.; Stulberg, Jonah J.; Auffenberg, Gregory B.; Surgery, School of MedicineObjective: To assess the reliability of peer-review of TURBT videos as a means to evaluate surgeon skill and its relationship to detrusor sampling. Methods: Urologists from an academic health system submitted TURBT videos in 2019. Ten blinded peers evaluated each surgeon's performance using a 10-item scoring instrument to quantify surgeon skill. Normalized composite skill scores for each surgeon were calculated using peer ratings. For surgeons submitting videos, we retrospectively reviewed all TURBT pathology results (2018-2019) to assess surgeon-specific detrusor sampling. A hierarchical logistic regression model was fit to evaluate the association between skill and detrusor sampling, adjusting for patient and surgeon factors. Results: Surgeon skill scores and detrusor sampling rates were determined for 13 surgeons performing 245 TURBTs. Skill scores varied from -6.0 to 5.1 [mean: 0; standard deviation (SD): 2.40]. Muscle was sampled in 72% of cases, varying considerably across surgeons (mean: 64.5%; SD: 30.7%). Among 8 surgeons performing >5 TURBTs during the study period, adjusted detrusor sampling rate was associated with sending separate deep specimens (odds ratio [OR]: 1.97; 95% confidence interval [CI]: 1.02-3.81, P = .045) but not skill (OR: 0.81; 95% CI: 0.57-1.17, P = .191). Conclusion: Surgeon skill was not associated with detrusor sampling, suggesting there may be other drivers of variability of detrusor sampling in TURBT.Item Assessing Resident Well-Being After the ABSITE: A Bad Time to Ask?(Wolters Kluwer, 2022-09-28) Cheung, Elaine O.; Hu, Yue-Yung; Jones, Andrew; Ma, Meixi; Schlick, Cary Jo R.; Moskowitz, Judith T.; Agarwal, Gaurava; Bilimoria, Karl Y.; Surgery, School of MedicineObjectives: Assess the association of residents' exam performance and transient emotions with their reports of burnout, suicidality, and mistreatment. Background: An annual survey evaluating surgical resident well-being is administered following the American Board of Surgery In-Training Examination (ABSITE). One concern about administering a survey after the ABSITE is that stress from the exam may influence their responses. Methods: A survey was administered to all general surgery residents following the 2018 ABSITE assessing positive and negative emotions (scales range from 0 to 12), as well as burnout, suicidality over the past 12 months, and mistreatment (discrimination, sexual harassment verbal/emotional or physical abuse) in the past academic year. Multivariable hierarchical regressions assessed the associations of exam performance and emotions with burnout, suicidality, and mistreatment. Results: Residents from 262 programs provided complete responses (N = 6987, 93.6% response rate). Residents reported high mean positive emotion (M = 7.54, SD = 2.35) and low mean negative emotion (M = 5.33, SD = 2.43). While residents in the bottom ABSITE score quartile reported lower positive and higher negative emotion than residents in the top 2 and 3 quartiles, respectively (P < 0.005), exam performance was not associated with the reported likelihood of burnout, suicidality, or mistreatment. Conclusions: Residents' emotions after the ABSITE are largely positive. Although poor exam performance may be associated with lower positive and higher negative emotion, it does not seem to be associated with the likelihood of reporting burnout, suicidality, or mistreatment. After adjusting for exam performance and emotions, mistreatment remained independently associated with burnout and suicidality. These findings support existing evidence demonstrating that burnout and suicidality are stable constructs that are robust to transient stress and/or emotions.Item Association Between Missed Doses of Chemoprophylaxis and VTE Incidence in a Statewide Colectomy Cohort(Wolters Kluwer, 2021) Khorfan, Rhami; Kreutzer, Lindsey; Love, Remi; Schlick, Cary Jo R.; Chia, Matthew; Bilimoria, Karl Y.; Yang, Anthony D.; Surgery, School of MedicineItem Association Between Surgical Technical Skill and Long-term Survival for Colon Cancer(American Medical Association, 2021) Brajcich, Brian C.; Stulberg, Jonah J.; Palis, Bryan E.; Chung, Jeanette W.; Huang, Reiping; Nelson, Heidi; Bilimoria, Karl Y.; Surgery, School of MedicineThis cohort study examines the association between surgical technical skill and overall survival following colectomy for colon cancer.