Utilization of Telemedicine among Medicare beneficiaries undergoing Hepatopancreatic Surgery during the COVID-19 Pandemic.

INTRODUCTION: Telemedicine may serve as an important avenue to address disparities in access to cancer care. We sought to define factors associated with telemedicine use among Medicare beneficiaries who underwent hepatopancreatic (HP) surgery, as well as characterize trends in telemedicine usage relative to community vulnerability based on the enactment of the Medicare telemedicine coverage waiver. METHODS: Patients who underwent HP surgery between 2013-2020 were identified from the Medicare Standard Analytic Files (SAF). Telemedicine utilization was assessed pre- versus post- implementation of the Medicare telemedicine coverage waiver; the county-level social vulnerability index (SVI) was obtained from the Center for Disease Control. Interrupted time series analysis with negative binomial and multivariable logistic regression methods were used to assess changes in telemedicine utilization after the implementation of the Medicare telemedicine coverage waiver relative to SVI. RESULTS: Pre-waiver telemedicine visits were scarce among 16,690 patients (0.2%, n = 28), while post-waiver telemedicine adoption was substantial among 3,301 patients (45.8%, n = 1,388). Post-waiver, the median patient age was 70 years (IQR, 66-74) with the majority of patients being age 65-69 (n = 994, 32.8%); 1,599 (52.8%) were female. Most patients self-identified as White (n = 2641, 87.1%), while a minority of patients self-identified as Black (n = 190, 6.3%), Asian (n = 18, 0.6%), Hispanic (n = 35, 1.2%), or Other/unknown (n = 147, 4.9%). On multivariable regression analysis, patients who lived in highly vulnerable counties (referent Low SVI; moderate SVI: OR 1.09, 95% CI 0.86-1.39, p = 0.449; high SVI: OR 0.72, 95% CI 0.55-0.94, p = 0.001) and individuals with advancing age (referent 18-64; 65-69, OR 0.68, 95%CI 0.54-0.86; 70-74, OR 0.56, 95%CI 0.44-0.71; 75-79, OR 0.57, 95%CI 0.44-0.75; 80-84, OR 0.43, 95%CI 0.30-0.61; 85 + , OR 0.25, 95%CI 0.13-0.49) had lower odds of utilizing telemedicine. In contrast, Black patients (referent White; OR 2.26, 95% CI 1.65-3.10) and patients with a higher CCI score > 2 (referent ≤ 2; OR 1.49, 95% CI 1.28-1.71) were more likely to use telemedicine (all p < 0.001). CONCLUSIONS: Medicare beneficiaries residing in counties with extreme vulnerability, as well as elderly individuals, were markedly less likely to use telemedicine services related to HP surgical episodes of care. The lower utilization of telemedicine in areas of high social vulnerability was attributable to concomitant lower rates of internet access in these areas.

Telehealth Utilization Among Surgical Oncology Patients at a Large Academic Cancer Center.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic increased the use of telehealth within medicine. Data on sociodemographic and clinical characteristics associated with telehealth utilization among cancer surgical patients have not been well-defined. METHODS: Cancer patients who had a surgical oncology visit at the James Cancer Hospital in March 2020-May 2021 were included. Patient demographic and clinical characteristics were recorded; access to modern information technology was measured using the Digital Divide Index (DDI). A logistic regression model was used to assess odds of receiving a telehealth. RESULTS: Among 2942 patients, median DDI was 18.2 (interquartile range 17.4-22.1). Patients were most often insured through managed care (n = 1459, 49.6%), followed by Medicare (n = 1109, 37.7%) and Medicaid (n = 267, 9.1%). Overall, 722 patients (24.5%) received at least one telehealth visit over the study period. On multivariable analysis, age (odds ratio [OR] 0.89, 95% confidence interval [CI] 0.80-0.98 per 10-year increase), sex (male vs. female: OR 1.83, 95% CI 1.45-2.32), cancer type (pancreatic vs. breast: OR 9.19, 95% CI 6.38-13.23; colorectal vs. breast: OR 5.31, 95% CI 3.71-7.58), insurance type (Medicare vs. Medicaid: OR 1.58, 95% CI 1.04-2.41) and county of residence (distant vs. neighboring: OR 1.33, 95% CI 1.06-1.66) were associated with increased odds of receiving a telehealth visit. Patients from high DDI counties were not less likely to receive telehealth visits versus patients from low DDI counties (OR 1.15, 95% CI 0.85-1.57). CONCLUSIONS: Several patient sociodemographic and clinical characteristics had an impact on the likelihood of receiving a telehealth visit versus an in-person visit, suggesting that telehealth may not be equally accessible to all surgical oncology patients.

Burnout Assessment Among Surgeons and Surgical Trainees During the COVID-19 Pandemic: A Systematic Review.

BACKGROUND: The objective of the current study was to summarize current research on burnout among surgical trainees and surgeons during the COVID-19 pandemic. METHODS: PubMed, SCOPUS, Embase, and Psych INFO were systematically searched for studies that evaluated burnout during the COVID-19 pandemic among surgical trainees and surgeons. RESULTS: A total of 29 articles met inclusion criteria, most of which originated from the United States (n = 18, 62.1%). Rates of burnout ranged from 6.0% to 86.0%. Personal factors responsible for burnout were fear of contracting/transmitting COVID-19 (8 studies, 27.6%), female gender (8, 27.6%), and younger age (5, 17.2%). Professional factors contributing to burnout included increased COVID-19 patient clinical load (6, 20.7%), limited work experience (6, 20.7%), reduction in operative cases (5, 17.2%) and redeployment to COVID-19 wards (4, 13.8%). The COVID-19 pandemic negatively impacted surgical education due to reduced number of operative cases (11, 37.9%), decreased hands-on experience (4, 13.8%), and not being able to complete case requirements (3, 10.34%). The shift of didactics to virtual formats (3, 10.3%), increased use of telemedicine (2, 6.9%), and improved camaraderie among residents (1, 3.4%) were viewed as positive consequences. CONCLUSION: COVID-19 related burnout was reported in as many as 1 in 2 surgical trainees and attending surgeons. Intrinsic- (i.e., gender, age), family- (i.e., family/being married/having children or being single/not having children), as well as work-related extrinsic- (i.e., work-force deployment, risk of infection/spread, changes in educational format) factors were strongly associated with risk of burnout. These factors should be considered when designing interventions to ameliorate burnout among surgical trainees and surgeons.

COVID-19 Positivity Following an In-Person Surgical Society Meeting: A Cross-Sectional Survey Study.

INTRODUCTION: Many surgical societies have recently resumed in-person meetings after canceling or adopting virtual formats during the COVID-19 pandemic. These meetings implemented safety measures to limit viral exposure and ensure participant safety. While there have been anecdotal reports of COVID-19 cases after attendance, no large-scale assessments have been undertaken. The objective of this study was to evaluate COVID-19 positivity following an in-person surgical society meeting. METHODS: An online survey was administered to participants of the Society for Asian Academic Surgeons annual meeting, which was held in Chicago, Illinois in September 2021. This survey assessed vaccination status, in-person versus virtual conference attendance, and COVID-19 testing and symptoms in the 7 d immediately following the meeting. RESULTS: Among the 220 meeting participants, 173 attended in person (79%). There were 91 survey respondents (41% response rate): 67% attending physicians, 27% trainees, and 6% medical students. Nearly, all (99%) reported being fully vaccinated against COVID-19. COVID-19 testing was sought within 7 d of the meeting by 15% of in-person respondents, and all reported negative results. Among individuals who were not tested, no one reported development of symptoms (cough, shortness of breath, fever, new loss of taste/smell, etc.). CONCLUSIONS: Among in-person attendees of a recent surgical society meeting, no one reported positive COVID-19 testing after the meeting, and individuals who were not tested denied developing symptoms. While these results are encouraging, societies hosting meetings should continue to proactively assess the safety of in-person meetings to promptly identify outbreaks and opportunities for improvement.

The 2020 Pandemics: Lessons Learned in Academic Surgery and Beyond.

2020 was a significant year because of the occurrence of two simultaneous public health crises: the coronavirus pandemic and the public health crisis of racism brought into the spotlight by the murder of George Floyd. The coronavirus pandemic has affected all aspects of health care, particularly the delivery of surgical care, surgical education, and academic productivity. The concomitant public health crisis of racism and health inequality during the viral pandemic highlighted opportunities for action to address gaps in surgical care and the delivery of public health services. At the 2021 Academic Surgical Congress Hot Topics session on flexibility and leadership, we also explored how our military surgeon colleagues can provide guidance in leadership during times of crisis. The following is a summary of the issues discussed during the session and reflections on the important lessons learned in academic surgery over the past year.

Intersectionality in cancer care: A systematic review of current research and future directions.

OBJECTIVES: The objective of the current review was to synthesize the literature on intersectionality relative to disparities across the cancer care continuum. A model to support future intersectional cancer research was proposed. METHODS: Web-based discovery services and discipline-specific databases were queried for both peer-reviewed and gray literature. Study screening and data extraction were facilitated through the Covidence software platform. RESULTS: Among 497 screened studies, 28 met study inclusion criteria. Most articles were peer-reviewed empirical studies (n = 22) that focused on pre-diagnosis/screening (n = 19) and included marginalized racial/ethnic (n = 22) identities. Pre-cancer diagnosis, sexual orientation and race influenced women's screening and vaccine behaviors. Sexual minority women, particularly individuals of color, were less likely to engage in cancer prevention behaviors prior to diagnosis. Race and socioeconomic status (SES) were important factors in patient care/survivorship with worse outcomes among non-white women of low SES. Emergent themes in qualitative results emphasized the importance of patient intersectional identities, as well as feelings of marginalization, fears of discrimination, and general discomfort with providers as barriers to seeking cancer care. CONCLUSIONS: Patients with intersectional identities often experience barriers to cancer care that adversely impact screening, diagnosis, treatment, as well as survivorship. The use of an "intersectional lens" as a future clinical and research framework will facilitate a more multidimensional and holistic approach to the care of cancer patients.

Patient Perspectives on Defining Textbook Outcomes Following Major Abdominal Surgery.

BACKGROUND: The composite metric textbook outcome (TO) has recently gained interest as a novel quality measure. However, the criteria for defining a TO have not been rigorously defined and patient perspectives on the characteristics of TO are unknown. METHODS: Patients who underwent major abdominal surgery at a single tertiary care center were administered a customized survey designed to ascertain their perspectives on defining TOs. The relationship between patient-reported and clinically defined TO rates was compared. RESULTS: Among 79 patients who underwent gastrointestinal (51%), pancreatic (29%), hepatic (18%), or other major abdominal (3%) operations, 57% were female and 86% had an ASA class ≥3. Most patients underwent surgery for malignancy (87%) with 60% undergoing an open operation. Patients most commonly valued no mortality following surgery (96%), no reoperation (75%), and having a margin negative resection (73%) as "extremely important." In contrast, those outcomes that were most commonly valued as "not important at all" or "minimally important" were receiving a blood transfusion (24%) and not having any complications (13%). Using previously published criteria for TOs, 47 (60%) patients were classified as having a clinically defined TO; in contrast, 68 patients (86%) self-reported their outcome was textbook. Self-reported responses were concordant with clinically defined TO criteria 63% of the time (McNemar's test: S=15.2, p<0.01, evidence of disagreement). CONCLUSION: There was significant discordance between patient-reported versus clinically defined measures of TOs, suggesting patients value other considerations beyond traditional factors when evaluating the success of their surgery. Future studies should delineate these relationships and incorporate these factors to refine TO definitions.

Marginalized patient identities and the patient-physician relationship in the cancer care context: a systematic scoping review.

PURPOSE: We sought to examine and categorize the current evidence on patient-physician relationships among marginalized patient populations within the context of cancer care using a systemic scoping review approach. METHODS: Web-based discovery services (e.g., Google Scholar) and discipline-specific databases (e.g., PubMed) were queried for articles on the patient-physician relationship among marginalized cancer patients. The marginalized populations of interest included (1) race and ethnicity, (2) gender, (3) sexual orientation and gender identity, (4) age, (5) disability, (6) socioeconomic status, and (7) geography (rural/urban). Study screening and data extraction were facilitated through the Covidence software platform. RESULTS: Of the 397 screened studies, 37 met study criteria-most articles utilized quantitative methodologies (n = 28). The majority of studies focused on racial and ethnic cancer disparities (n = 27) with breast cancer (n = 20) as the most common cancer site. Trust and satisfaction with the provider were the most prevalent issues cited in the patient-physician relationship. Differences in patient-physician communication practices and quality were also frequently discussed. Overall, studies highlighted the need for increased culturally congruent care among providers. CONCLUSION: Results from this review suggest marginalized cancer patients face significant barriers in establishing culturally and linguistically congruent patient-physician relationships. Future studies should focus on the intersectionality of multiple marginalized identities and optimization of the patient-physician relationship.

The Influence of Patient and Provider Religious and Spiritual Beliefs on Treatment Decision Making in the Cancer Care Context.

BACKGROUND: Providers often underestimate the influence of patient religious and spiritual (R&S) needs. The current study sought to determine the influence of R&S beliefs on treatment decision making among patients and providers in the context of cancer care. METHODS: We conducted a systematic review of the literature using web-based search engines and discipline-specific databases. Search terms included a combination of the following Medical Subject Headings and key terms: "cancer,""spirituality,""religion," and "decision making." We used Covidence to screen relevant studies and extracted data into Microsoft Excel. RESULTS: Among 311 screened studies, 32 met inclusion/exclusion criteria. Most studies evaluated the patient perspective (n = 29), while 2 studies evaluated the provider perspective and 1 study examined both. In assessing patient R&S relative to treatment decision making, we thematically characterized articles according to decision-making contexts, including general (n = 11), end-of-life/advance care planning (n = 13), and other: specific (n = 8). Specific contexts included, but were not limited to, clinical trial participation (n = 2) and use of complementary and alternative medicine (n = 4). Within end-of-life/advance care planning, there was a discrepancy regarding how R&S influenced treatment decision making. The influence of R&S on general treatment decision making was both active and passive, with some patients wanting more direct integration of their R&S beliefs in treatment decision making. In contrast, other patients were less aware of indirect R&S influences. Patient perception of the impact of R&S on treatment decision making varied relative to race/ethnicity, being more pronounced among Black patients. CONCLUSION: Most articles focused on R&S relative to treatment decision making at the end of life, even though R&S appeared important across the care continuum. To improve patient-centered cancer care, providers need to be more aware of the impact of R&S on treatment decision making.

International Delphi Expert Consensus on Safe Return to Surgical and Endoscopic Practice: From the Coronavirus Global Surgical Collaborative.

OBJECTIVE: The aim of this work is to formulate recommendations based on global expert consensus to guide the surgical community on the safe resumption of surgical and endoscopic activities. BACKGROUND: The COVID-19 pandemic has caused marked disruptions in the delivery of surgical care worldwide. A thoughtful, structured approach to resuming surgical services is necessary as the impact of COVID-19 becomes better controlled. The Coronavirus Global Surgical Collaborative sought to formulate, through rigorous scientific methodology, consensus-based recommendations in collaboration with a multidisciplinary group of international experts and policymakers. METHODS: Recommendations were developed following a Delphi process. Domain topics were formulated and subsequently subdivided into questions pertinent to different aspects of surgical care in the COVID-19 crisis. Forty-four experts from 15 countries across 4 continents drafted statements based on the specific questions. Anonymous Delphi voting on the statements was performed in 2 rounds, as well as in a telepresence meeting. RESULTS: One hundred statements were formulated across 10 domains. The statements addressed terminology, impact on procedural services, patient/staff safety, managing a backlog of surgeries, methods to restart and sustain surgical services, education, and research. Eighty-three of the statements were approved during the first round of Delphi voting, and 11 during the second round. A final telepresence meeting and discussion yielded acceptance of 5 other statements. CONCLUSIONS: The Delphi process resulted in 99 recommendations. These consensus statements provide expert guidance, based on scientific methodology, for the safe resumption of surgical activities during the COVID-19 pandemic.

Impact of visitor restriction rules on the postoperative experience of COVID-19 negative patients undergoing surgery.

BACKGROUND: Many hospitals have implemented visitor restriction policies in response to the coronavirus disease 2019 pandemic. Because caregivers serve an important role in postoperative recovery, the purpose of this study was to evaluate the impact of visitor restrictions on the postoperative experience of coronavirus disease 2019-negative patients undergoing surgery. METHODS: Patients who underwent surgery immediately before or after the implementation of a visitor restriction policy were enrolled. Patients were surveyed on their inpatient experience and preparedness for discharge using items adapted from validated questionnaires. RESULTS: Among 128 eligible patients, 117 agreed to participate (91.4% response rate): 58 (49.6%) in the Visitor Cohort and 59 (50.4%) in the No-Visitor Cohort. Mean age was 57.5 years (standard deviation 13.9) and 66 (56.4%) were female. Among all patients, 47.8% underwent oncologic surgery, 31.6% transplant, and 20.5% general or other. Patients in the No-Visitor Cohort were less likely to report complete satisfaction with the hospital experience (80.7% vs 66.0%, P = .044), timely receipt of medications (84.5% vs 69.0%, P = .048), and assistance getting out of bed (70.7% vs 51.7%, P = .036). No-Visitor Cohort patients were less likely to feel that their discharge preferences were adequately considered (79.3% vs 54.2%, P = .004). Qualitative analysis of patient responses highlighted the consistent psychosocial support provided by visitors after surgery (84.5%), and patients in the No-Visitor Cohort reported social isolation due to lack of psychosocial support (50.8%). CONCLUSION: The implementation of hospital visitor restriction policies may adversely impact the postoperative experience of coronavirus disease 2019-negative patients undergoing surgery. These findings highlight the urgent need for novel patient-centered strategies to improve the postoperative experience of patients during ongoing or future disruptions to routine hospital practice.

The management of surgical patients during the coronavirus disease 2019 (COVID-19) pandemic.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has raised several issues regarding the management of surgical patients. The aim of the current study was to clarify the management of oncologic and surgical patients during the pandemic. METHODS: Relevant publications reporting on the epidemiology of the pandemic, the diagnosis of the severe acute respiratory syndrome coronavirus 2 infection, and the clinical management of cancer and surgical patients, as well as studies concerning health care workers' safety, were included. The last date of research for this study was April 4, 2020. RESULTS: We analyzed 28 papers. Real-time polymerase chain reaction was considered the gold standard for the diagnosis of COVID-19, and computed tomography scans were considered useful for cases of diagnostic uncertainty. Cancer patients and surgical patients were confirmed to be particularly at risk of infection and negative outcome. To guarantee adequate care to these patients, while minimizing the risk for infection, the early postponing of elective surgery, the creation of COVID-free facilities and the identification of COVID- dedicated operating theaters and teams have been proposed. The correct use of personal protective equipment was also strongly advocated, along with the institution of facilities for the psychologic support of health care workers. CONCLUSION: Clinicians should be aware of the importance of providing adequate care to patients with urgent and nondeferrable clinical issues, such as cancer. Every effort should be made to contain the virus spread in the hospital setting. Also, clinicians should value the importance of self-protection and mental health care.

Responsible Return to Essential and Non-Essential Surgery During the COVID-19 Pandemic.

Non-essential surgery had largely been suspended during the COVID-19 Pandemic. Enormous amounts of resources were utilized to shift surgical practices to a "disaster footing" with most elective surgeons assuming new roles to offset the anticipated burden from surgical and medical personnel delivering acute care. As the number of COVID-19-infected patients began to plateau in the state of Ohio, a four-phase "Responsible Return to Surgery" approach was adopted in concert with the Ohio Department of Health and the Ohio Hospital Association. This approach was adopted understanding that a simple return to the status quo prior to the COVID-19 pandemic might be harmful to patients, providers, and staff. The discrete phases undertaken at our quaternary care institution for a responsible return to non-essential surgery are outlined with the goal of ensuring timely care, minimizing community transmission, and preserving personal protective equipment. Operationalizing these phases relied upon the widespread use of telehealth, systematic COVID-19 testing, and real-time monitoring of hospital and personal protective equipment resources.

COVID-19 Pandemic and Surgical Oncology: Preserving the Academic Mission.

BACKGROUND: The global pandemic of respiratory disease cause by the novel human coronavirus (SARS-CoV-2) has caused untold suffering, loss of life and upheaval in society. The pandemic has lead to massive redirection of health care resources to treat the surge of COVID-19 patients, and enforcement of social distancing to reduce the rate of transmission. METHODS: Editorial Board members provided observations of the implications of the pandemic on academic surgical oncology. RESULTS: Delivery of health care to other populations including cancer patients has been significantly disrupted. The implications both short term and long term threaten preservation of the academic mission in medicine at large, and certainly in the field of surgical oncology. CONCLUSIONS: The effects on surgical oncology training, research and clinical trials are major.