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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 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.Item 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 MedicineBackground: 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.Item 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 MedicineIntroduction: 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.Item Barriers to Post-Discharge Monitoring and Patient-Clinician Communication: A Qualitative Study(Elsevier, 2021) Brajcich, Brian C.; Shallcross, Meagan L.; Johnson, Julie K.; Joung, Rachel Hae-Soo; Iroz, Cassandra B.; Holl, Jane L.; Bilimoria, Karl Y.; Merkow, Ryan P.; Surgery, School of MedicineIntroduction: As postoperative length of stay has decreased for many operations, the proportion of complications occurring post-discharge is increasing. Early identification and management of these complications requires overcoming barriers to effective post-discharge monitoring and communication. The aim of this study was to identify barriers to post-discharge monitoring and patient-clinician communication through a qualitative study of surgical patients and clinicians. Materials and methods: Semi-structured interviews and focus groups were held with gastrointestinal surgery patients and clinicians. Participants were asked about barriers to post-discharge monitoring and communication. Each transcript was coded by 2 of 4 researchers, and recurring themes related to communication and care barriers were identified. Results: A total of 15 patients and 17 clinicians participated in interviews and focus groups. Four themes which encompassed barriers to post-discharge monitoring and communication were identified from patient interviews, and 4 barriers were identified from clinician interviews and focus groups. Patient-identified barriers included education and expectation setting, technology access and literacy, availability of resources and support, and misalignment of communication preferences, while clinician-identified barriers included health education, access to clinical team, healthcare practitioner time constraints, and care team experience and consistency. Conclusions: Multiple barriers exist to effective post-discharge monitoring and patient-clinician communication among surgical patients. These barriers must be addressed to develop an effective system for post-discharge care after surgery.Item Evaluation of Emergency Department Treat-and-Release Encounters After Major Gastrointestinal Surgery(Wiley, 2023) Brajcich, Brian C.; Johnson, Julie K.; Holl, Jane L.; Bilimoria, Karl Y.; Shallcross, Meagan L.; Chung, Jeanette; Joung, Rachel Hae Soo; Iroz, Cassandra B.; Odell, David D.; Bentrem, David J.; Yang, Anthony D.; Franklin, Patricia D.; Slota, Jennifer M.; Silver, Casey M.; Skolarus, Ted; Merkow, Ryan P.; Surgery, School of MedicineBackground and objectives: Emergency department (ED) utilization after gastrointestinal cancer operations is poorly characterized. Our study objectives were to determine the incidence of, reasons for, and predictors of ED treat-and-release encounters after gastrointestinal cancer operations. Methods: Patients who underwent elective esophageal, hepatobiliary, gastric, pancreatic, small intestinal, or colorectal operations for cancer were identified in the 2015-2017 Healthcare Cost and Utilization Project State Inpatient and State Emergency Department Databases for New York, Maryland, and Florida. The primary outcomes were the incidence of ED treat-and-release encounters and readmissions within 30 days of discharge. Results: Among 51 527 patients at 406 hospitals, 4047 (7.9%) had an ED treat-and-release encounter, and 5573 (10.8%) had an ED encounter with readmission. In total, 40.7% of ED encounters were treat-and-release encounters. ED treat-and-release encounters were most frequently for pain (12.0%), device/ostomy complaints (11.7%), or wound complaints (11.4%). ED treat-and-release encounters predictors included non-Hispanic Black race/ethnicity (odds ratio [OR] 1.24, 95% confidence interval [CI] 1.12-1.37) and Medicare (OR 1.27, 95% CI 1.16-1.40) or Medicaid (OR 1.82, 95% CI 1.62-2.40) coverage. Conclusions: ED treat-and-release encounters are common after major gastrointestinal operations, making up nearly half of postdischarge ED encounters. The reasons for ED treat-and-release encounters differ from those for ED encounters with readmissions.Item Experiences With Unionization Among General Surgery Resident Physicians, Faculty, and Staff(American Medical Association, 2024-07-01) Foote, Darci C.; Rosenblatt, Audrey E.; Amortegui, Daniela; Diaz, Carmen M.; Brajcich, Brian C.; Schlick, Cary Jo R.; Bilimoria, Karl Y.; Hu, Yue-Yung; Johnson, Julie K.; Surgery, School of MedicineImportance: Labor unions are a mechanism for employee advocacy, but their role in surgery resident wellness is poorly characterized. Objective: To understand experiences with unionization among general surgery residents and residency program faculty and staff. Design, setting, and participants: This exploratory qualitative study included data from the Surgical Education Culture Optimization Through Targeted Interventions Based on National Comparative Data (SECOND) trial. In the exploratory phase of the SECOND trial (from March 6, 2019, to March 12, 2020), semistructured interviews about wellness were conducted with residents, faculty (attending physicians), and staff (program administrators) at 15 general surgery residency programs. Unionization was identified as an emergent theme in the interviews. Data analysis was performed from March 2019 to May 2023. Main outcomes and measures: The main outcome was resident and faculty experience with resident labor unions. In the qualitative analysis, lexical searches of interview transcripts identified content regarding resident labor unions. A codebook was developed inductively. Transcripts were coded by dyads, using a constant comparative approach, with differences reconciled by consensus. Results: A total of 22 interview transcripts were identified with relevant content. Of these, 19 were individual interviews conducted with residents (n = 10), faculty (n = 4), administrative staff (n = 1), a program director (n = 1), a department chair (n = 1), and designated institutional officials (n = 2), and 3 were from resident focus groups. Residents from all postgraduate year levels, including professional development (ie, research) years, were represented. Interviewees discussed resident unions at 2 programs (1 recently unionized and 1 with a decades-long history). Interviewees described the lack of voice and the lack of agency as drivers of unionization ("Residents…are trying to take control of their well-being"). Increased salary stipends and/or housing stipends were the most concretely identified union benefits. Unanticipated consequences of unionization were described by both residents and faculty, including (1) irrelevance of union-negotiated benefits to surgical residents, (2) paradoxical losses of surgery department-provided benefits, and (3) framing of resident-faculty relationships as adversarial. Union executives were noted to be nonphysician administrators whose participation in discussions about clinical education progression may increase the time and effort to remediate a resident and/or reduce educators' will to meaningfully intervene. Active surgical resident participation within the union allows for an understanding of surgical trainees' unique needs and reduced conflict. Conclusions and relevance: In this qualitative study, unionization was a mechanism for resident voice and agency; the desire to unionize likely highlighted the lack of other such mechanisms in the training environment. However, these findings suggest that unionization may have had unintended consequences on benefits, flexibility, and teaching. Effective advocacy, whether within or outside the context of a union, was facilitated by participation from surgical residents. Future research should expand on this exploratory study by including a greater number of institutions and investigating the evolution of themes over time.Item Management of colorectal cancer during the COVID‐19 pandemic: Recommendations from a statewide multidisciplinary cancer collaborative(Wiley, 2022) Brajcich, Brian C.; Benson, Al B.; Gantt, Gerald, Jr.; Eng, Oliver S.; Marsh, Robert W.; Mulcahy, Mary F.; Polite, Blase N.; Shogan, Benjamin D.; Yang, Anthony D.; Merkow, Ryan P.; Surgery, School of MedicineCOVID-19 has resulted in significant disruptions in cancer care. The Illinois Cancer Collaborative (ILCC), a statewide multidisciplinary cancer collaborative, has developed expert recommendations for triage and management of colorectal cancer when disruptions occur in usual care. Such recommendations would be applicable to future outbreaks of COVID-19 or other large-scale disruptions in cancer care.Item National Evaluation of the Association Between Resident Labor Union Participation and Surgical Resident Well-being(American Medical Association, 2021-09-01) Brajcich, Brian C.; Chung, Jeanette W.; Wood, Douglas E.; Horvath, Karen D.; Tolley, Philip D.; Yates, Elizabeth F.; Are, Chandrakanath; Ellis, Ryan J.; Hu, Yue-Yung; Bilimoria, Karl Y.; Surgery, School of MedicineImportance: Labor unions are purported to improve working conditions; however, little evidence exists regarding the effect of resident physician unions. Objective: To evaluate the association of resident unions with well-being, educational environment, salary, and benefits among surgical residents in the US. Design, setting, and participants: This national cross-sectional survey study was based on a survey administered in January 2019 after the American Board of Surgery In-Training Examination (ABSITE). Clinically active residents at all nonmilitary US general surgery residency programs accredited by the American Council of Graduate Medical Education who completed the 2019 ABSITE were eligible for participation. Data were analyzed from December 5, 2020, to March 16, 2021. Exposures: Presence of a general surgery resident labor union. Rates of labor union coverage among non-health care employees within a region were used as an instrumental variable (IV) for the presence of a labor union at a residency program. Main outcomes and measures: The primary outcome was burnout, which was assessed using a modified version of the abbreviated Maslach Burnout Inventory and was defined as experiencing any symptom of depersonalization or emotional exhaustion at least weekly. Secondary outcomes included suicidality, measures of job satisfaction, duty hour violations, mistreatment, educational environment, salary, and benefits. Results: A total of 5701 residents at 285 programs completed the pertinent survey questions (response rate, 85.6%), of whom 3219 (56.5%) were male, 3779 (66.3%) were White individuals, 449 (7.9%) were of Hispanic ethnicity, 4239 (74.4%) were married or in a relationship, and 1304 (22.9%) had or were expecting children. Among respondents, 690 residents were from 30 unionized programs (10.5% of programs). There was no difference in burnout for residents at unionized vs nonunionized programs (297 [43.0%] vs 2175 [43.4%]; odds ratio [OR], 0.92 [95% CI, 0.75-1.13]; IV difference in probability, 0.15 [95% CI, -0.11 to 0.42]). There were no significant differences in suicidality, job satisfaction, duty hour violations, mistreatment, educational environment, salary, or benefits except that unionized programs more frequently offered 4 weeks instead of 2 to 3 weeks of vacation (27 [93.1%] vs 52 [30.6%]; OR, 19.18 [95% CI, 3.92-93.81]; IV difference in probability, 0.77 [95% CI, 0.09-1.45]) and more frequently offered housing stipends (10 [38.5%] vs 9 [16.1%]; OR, 2.15 [95% CI, 0.58-7.95]; IV difference in probability, 0.62 [95% CI 0.04-1.20]). Conclusions and relevance: In this evaluation of surgical residency programs in the US, unionized programs offered improved vacation and housing stipend benefits, but resident unions were not associated with improved burnout, suicidality, job satisfaction, duty hour violations, mistreatment, educational environment, or salary.Item Unbundling Bundles: Evaluating the Association of Individual Colorectal Surgical Site Infection Reduction Bundle Elements on Infection Rates in a Statewide Collaborative(Wolters Kluwer, 2022) Schlick, Cary Jo R.; Huang, Reiping; Brajcich, Brian C.; Halverson, Amy L.; Yang, Anthony D.; Kreutzer, Lindsey; Bilimoria, Karl Y.; McGee, Michael F.; Illinois Surgical Quality Improvement Collaborative; Surgery, School of MedicineBACKGROUND: Surgical site infection reduction bundles are effective but can be complex and resource intensive. Understanding which bundle elements are associated with reduced surgical site infections may guide concise bundle implementation. OBJECTIVE: To evaluate the association of individual surgical site infection reduction bundle elements with infection rates. DESIGN: Post-hoc analysis of a prospective cohort study SETTING: Illinois Surgical Quality Improvement Collaborative hospitals PATIENTS: Elective colorectal resections at participating hospitals from 2016–2017 INTERVENTIONS: 16-element colorectal surgical site infection reduction bundle MAIN OUTCOME MEASURES: Surgical site infection rates were compared among patients by adherence with each bundle element using Chi-squared tests and multivariable logistic regression. Principal component analysis identified composites of correlated bundle elements. Coincidence analysis identified combinations of bundle elements or principal component composites associated with the absence of surgical site infection. RESULTS: Among 2,722 patients, 192 (7.1%) developed a surgical site infection. Infections were less likely when oral antibiotics (OR 0.63 [95% CI 0.41–0.97]), wound protectors (OR 0.55 [95% CI 0.37–0.81]), and occlusive dressings (OR 0.71 [95% CI 0.51–1.00]) were used. Bundle elements were reduced into 5 principal component composites. Adherence with the combination of (1) oral antibiotics, (2) wound protector, or (3) redosing intravenous antibiotic prophylaxis plus chlorhexidine-alcohol intraoperative skin preparation were associated with the absence of infection (consistency=0.94, coverage=0.96). Four of the five principal component composites in various combinations were associated with the absence of surgical site infection, while the composite consisting of occlusive dressing placement, postoperative dressing removal, and daily postoperative chlorhexidine incisional cleansing had no association with the outcome. LIMITATIONS: The inclusion of hospitals engaged in quality improvement initiatives may limit the generalizability of these data. CONCLUSION: Bundle elements had varying association with infection reduction. Implementation of colorectal surgical site infection reduction bundles should focus on the specific elements associated with low surgical site infections. See Video Abstract at http://links.lww.com/DCR/Bxxx.