Browsing by Author "Bilimoria, Karl Y."

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    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 Medicine
    Objective: 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.
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    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 Medicine
    Background: 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.
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    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 Medicine
    Objectives: 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.
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    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 Medicine
    Objectives: 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.
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    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 Medicine
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    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 Medicine
    This cohort study examines the association between surgical technical skill and overall survival following colectomy for colon cancer.
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    Association of Preoperative Smoking with Complications Following Major Gastrointestinal Surgery
    (Elsevier, 2022) Brajcich, Brian C.; Yuce, Tarik K.; Merkow, Ryan P.; Bilimoria, Karl Y.; McGee, Michael F.; Zhan, Tiannan; Odell, David D.; Surgery, School of Medicine
    Background: Understanding modifiable surgical risk factors is essential for preoperative optimization. We evaluated the association between smoking and complications following major gastrointestinal surgery. Methods: Patients who underwent elective colorectal, pancreatic, gastric, or hepatic procedures were identified in the 2017 ACS NSQIP dataset. The primary outcome was 30-day death or serious morbidity (DSM). Secondary outcomes included pulmonary complications, wound complications, and readmission. Multivariable logistic regression was used to evaluate the association between smoking and these outcomes. Results: A total of 46,921 patients were identified, of whom 7,671 (16.3%) were smokers. Smoking was associated with DSM (23.2% vs. 20.4%, OR 1.15 [1.08-1.23]), wound complications (13.0% vs. 10.4%, OR 1.24 [1.14-1.34]), pulmonary complications (4.9% vs 2.9%, OR 1.93 [1.70-2.20]), and unplanned readmission (12.6% vs. 11%, OR 1.14 [95% CI 1.06-1.23]). Conclusions: Smoking is associated with complications following major gastrointestinal surgery. Patients who smoke should be counseled prior to surgery regarding risks.
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    Barriers and Facilitators to Implementing Patient-Reported Outcome Monitoring in Gastrointestinal Surgery
    (Elsevier, 2023) Iroz, Cassandra B.; Johnson, Julie K.; Ager, Meagan S.; Joung, Rachel Hae-Soo; Brajcich, Brian C.; Cella, David; Franklin, Patricia D.; Holl, Jane L.; Bilimoria, Karl Y.; Merkow, Ryan P.; Surgery, School of Medicine
    Introduction: More than 30% of patients experience complications after major gastrointestinal (GI) surgery, many of which occur after discharge when patients and families must assume responsibility for monitoring. Patient-reported outcomes (PROs) have been proposed as a tool for remote monitoring to identify deviations in recovery, and recognize and manage complications earlier. This study's objective was to characterize barriers and facilitators to the use of PROs as a patient monitoring tool following GI surgery. Methods: We conducted semistructured interviews with GI surgery patients and clinicians (surgeons, nurses, and advanced practitioners). Patients and clinicians were asked to describe their experience using a PRO monitoring system in three surgical oncology clinics. Using a phenomenological approach, research team dyads independently coded the transcripts using an inductively developed codebook and the constant comparative approach with differences reconciled by consensus. Results: Ten patients and five clinicians participated in the interviews. We identified four overarching themes related to functionality, workflow, meaningfulness, and actionability. Functionality refers to barriers faced by clinicians and patients in using the PRO technology. Workflow represents problematic integration of PROs into the clinical workflow and need for setting expectations with patients. Meaningfulness refers to lack of patient and clinician understanding of the impact of PROs on patient care. Finally, actionability reflects barriers to follow-up and practical use of PRO data. Conclusions: While use of PRO systems for postoperative patient monitoring have expanded, significant barriers persist for both patients and clinicians. Implementation enhancements are needed to optimize functionality, workflow, meaningfulness, and actionability.
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    Barriers and facilitators to interdisciplinary communication during consultations: a qualitative study
    (BMJ, 2021-09-02) Liu, Pingyang; Lyndon, Audrey; Holl, Jane L.; Johnson, Julie; Bilimoria, Karl Y.; Stey, Anne M.; Surgery, School of Medicine
    Objective: Communication failures between clinicians lead to poor patient outcomes. Critically injured patients have multiple injured organ systems and require complex multidisciplinary care from a wide range of healthcare professionals and communication failures are abundantly common. This study sought to determine barriers and facilitators to interdisciplinary communication between the consulting trauma, intensive care unit (ICU) team and specialty consultants for critically injured patients at an urban, safety-net, level 1 trauma centre. Design: An observational qualitative study of barriers and facilitators to interdisciplinary communication. Setting: We conducted observations of daily rounds in two trauma surgical ICUs and recorded the most frequently consulted teams. Participants: Key informant interviews after presenting clinical vignettes as discussion prompts were conducted with a broad range of clinicians from the ICUs and physicians and nurse practitioners from the consultant teams who were identified during the observations. Interviews were recorded and transcribed verbatim. Data of these 10 interviews were combined with primary transcript data from prior study (25 interviews) and analysed together because of the same setting with same themes. Independent coding of the transcripts, with iterative reconciliation, was performed by two coders. Outcomes measures: Facilitators and barriers of interdisciplinary communication were identified. Results: A total of 35 interview transcripts were analysed. Cardiology and interventional radiology were the most frequently consulted teams. Consulting and consultant clinicians reported that perceived accessibility from the team seeking a consultation and the consultant team impacted interdisciplinary communication. Accessibility had a physical dimension as well as a psychological dimension. Accessibility was demonstrated by responsiveness between clinicians of different disciplines and in turn facilitated interdisciplinary communication. Social norms, cognitive biases, hierarchy and relationships were reported as both facilitators and barriers to accessibility, and therefore, interdisciplinary communication. Conclusion: Accessibility impacted interdisciplinary communication between the consulting and the consultant team. Article summary: Elucidates barriers and facilitators to interdisciplinary communication between consulting and consultant teams.
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    Behind the Curtain: Impact of Anesthesia Volume on Outcomes
    (American Medical Association, 2021) Joung, Rachel Hae-Soo; Bilimoria, Karl Y.; Merkow, Ryan P.; Surgery, School of Medicine