Perceptions on gender disparity in surgery and surgical leadership: A multicenter mixed methods study.

BACKGROUND: Our objective was to identify perceptions of the environment for women in surgery among 4 academic institutions. METHODS: Faculty surgeons and senior surgery residents were randomly selected to participate in a parallel study with concurrent quantitative and qualitative data collection. Outcomes were perceptions of the environment for women in surgery. Measures included semi-structured interviews, survey responses, and responses to scenarios. RESULTS: Saturation was achieved after 36 individuals were interviewed: 14 female (8 faculty, 6 residents) and 22 male (18 faculty, 4 residents) surgeons. Men (100%) and women (86%) reported gender disparity in surgery and identified 6 major categories which influence disparity: definitions of gender disparity, gaps in mentoring, family responsibility, disparity in leave, unequal pay, and professional advancement. Overall 94% of participants expressed concerns with gaps in mentoring, but 64% of women versus 14% of men reported difficulties finding role models who faced similar obstacles. Over half (53%) reported time with loved ones as their biggest sacrifice to advance professionally. Both female and male respondents expressed system-based biases favoring individuals willing to sacrifice family. A global subconscious bias against the expectations, abilities, and goals of female surgeons were perceived to impede promotion and advancement. CONCLUSION: Both female and male surgeons report substantial gender-based barriers in surgery for women. Despite improvements, fundamental issues such as lack of senior role models, limited support for surgeons with families, and disparities in hiring and promotion persist. This is an opportunity to make substantive changes to the system and eliminate barriers for women joining surgery, advancing their careers, and achieving their goals in a timely fashion.

Accelerated enhanced Recovery following Minimally Invasive colorectal cancer surgery (RecoverMI): a study protocol for a novel randomised controlled trial.

INTRODUCTION: Definitive treatment of localised colorectal cancer involves surgical resection of the primary tumour. Short-stay colectomies (eg, 23-hours) would have important implications for optimising the efficiency of inpatient care with reduced resource utilisation while improving the overall recovery experience with earlier return to normalcy. It could permit surgical treatment of colorectal cancer in a wider variety of settings, including hospital-based ambulatory surgery environments. While a few studies have shown that discharge within the first 24 hours after minimally invasive colectomy is possible, the safety, feasibility and patient acceptability of a protocol for short-stay colectomy for colorectal cancer have not previously been evaluated in a prospective randomised study. Moreover, given the potential for some patients to experience a delay in recovery of bowel function after colectomy, close outpatient monitoring may be necessary to ensure safe implementation. METHODS AND ANALYSIS: In order to address this gap, we propose a prospective randomised trial of accelerated enhanced Recovery following Minimally Invasive colorectal cancer surgery (RecoverMI) that leverages the combination of minimally invasive surgery with enhanced recovery protocols and early coordinated outpatient remote televideo conferencing technology (TeleRecovery) to improve postoperative patien-provider communication, enhance postoperative treatment navigation and optimise postdischarge care. We hypothesise that RecoverMI can be safely incorporated into multidisciplinary practice to improve patient outcomes and reduce the overall 30-day duration of hospitalisation while preserving the quality of the patient experience. ETHICS AND DISSEMINATION: RecoverMI has received institutional review board approval and funding from the American Society of Colorectal Surgeons (ASCRS; LPG103). Results from RecoverMI will be published in a peer-reviewed publication and be used to inform a multisite trial. TRIAL REGISTRATION NUMBER: NCT02613728; Pre-results.

Ventral Hernia Management: Expert Consensus Guided by Systematic Review.

OBJECTIVE: To achieve consensus on the best practices in the management of ventral hernias (VH). BACKGROUND: Management patterns for VH are heterogeneous, often with little supporting evidence or correlation with existing evidence. METHODS: A systematic review identified the highest level of evidence available for each topic. A panel of expert hernia-surgeons was assembled. Email questionnaires, evidence review, panel discussion, and iterative voting was performed. Consensus was when all experts agreed on a management strategy. RESULTS: Experts agreed that complications with VH repair (VHR) increase in obese patients (grade A), current smokers (grade A), and patients with glycosylated hemoglobin (HbA1C) ≥ 6.5% (grade B). Elective VHR was not recommended for patients with BMI ≥ 50 kg/m (grade C), current smokers (grade A), or patients with HbA1C ≥ 8.0% (grade B). Patients with BMI= 30-50 kg/m or HbA1C = 6.5-8.0% require individualized interventions to reduce surgical risk (grade C, grade B). Nonoperative management was considered to have a low-risk of short-term morbidity (grade C). Mesh reinforcement was recommended for repair of hernias ≥ 2 cm (grade A). There were several areas where high-quality data were limited, and no consensus could be reached, including mesh type, component separation technique, and management of complex patients. CONCLUSIONS: Although there was consensus, supported by grade A-C evidence, on patient selection, the safety of short-term nonoperative management, and mesh reinforcement, among experts; there was limited evidence and broad variability in practice patterns in all other areas of practice. The lack of strong evidence and expert consensus on these topics has identified gaps in knowledge where there is need of further evidence.

Underserved Patients Seeking Care for Ventral Hernias at a Safety Net Hospital: Impact on Quality of Life and Expectations of Treatment.

BACKGROUND: The purpose of this study was to identify issues important to patients in their decision-making, expectations, and satisfaction when seeking treatment for a ventral hernia. STUDY DESIGN: An exploratory qualitative study was conducted of adult patients with ventral hernias seeking care at a safety-net hospital. Two semi-structured interviews were conducted with each patient: before and 6 months after surgical consultation. Interviews were audiotaped, transcribed, and coded using latent content analysis until data saturation was achieved. RESULTS: Of patients completing an initial interview (n = 30), 27 (90%) completed follow-up interviews. Half of the patients were Spanish-speaking, one-third had a previous ventral hernia repair, and two-thirds underwent initial nonoperative management after surgical consultation. Patient-described factors guiding management decisions included impact on quality of life, primarily pain and limited function; overwhelming challenges to meeting surgical criteria, primarily obesity; and assuming responsibility to avoid recurrence. Patients were uninformed regarding potential poor outcomes and contributing factors, even among patients with a previous ventral hernia repair, with most attributing recurrence to inadequate self-management. CONCLUSIONS: Understanding patients' perspective is crucial to engaging them as stakeholders in their care, addressing their concerns, and improving clinical and patient-centered outcomes. Patient reports suggest how care can be improved through developing more effective strategies for addressing patients' concerns during nonoperative management, preoperative risk reduction strategies that are sensitive to their sociodemographic characteristics, treatment plans that harness patients' willingness for self-management, and patient education and decision-making tools.

A systematic review of randomized controlled trials and reviews in the management of ventral hernias.

BACKGROUND: The literature supporting ventral hernia management is growing; however, it is unclear whether the quality of work is improving. We hypothesize that the quality of clinical ventral hernia research has improved over the past 2.5 decades. METHODS: A review of MEDLINE, Scopus, and Cochrane databases was conducted for all ventral hernia studies from January 1, 1980 to May 1, 2015. Relevant abstracts were assigned a level according to the Oxford Center for Evidence-Based Medicine. Reviews, and meta-analyses were graded using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Checklist and randomized controlled trials (RCTs) using the Consolidated Standards of Reporting Trials (CONSORT) checklist. Studies that did not fulfill at least 70% of the elements for the PRISMA (19/27) or CONSORT (26/37) checklists were considered to contain substantial methodological flaws. RESULTS: Of 12,431 citations, 1336 met criteria for quality evaluation. Level 1 studies were sparse (n = 104, 7.8%), and most were level 2 or 3 (n = 463, 34.7%) or 4 (n = 769, 57.6%). Of the level 1 studies, 37 (35.6%) were RCTs, 61(58.7%) were reviews and/or meta-analyses, and 6 (5.8%) were consensus statements. Most RCTs and reviews and/or meta-analyses contained substantial methodological flaws (75.7%, 75.8%). Critical areas of weakness in RCTs were explaining losses and exclusions after randomization and/or allocation and reporting determination of sample size. For reviews and/or meta-analyses, areas of weakness were presenting an electronic search strategy and providing an assessment of risk of bias before pooling data. Linear regressions of PRISMA and CONSORT scores demonstrated improvement over time (PRISMA slope 0.95, R(2) = 0.24; CONSORT slope 0.34, R(2) = 0.08). CONCLUSIONS: Although the quality of literature guiding ventral hernia management has improved over time, there is room for improvement.

Do Socioeconomic Factors and Race Determine the Likelihood of Breast-Conserving Surgery?

BACKGROUND: Racial disparities in the use of breast-conserving surgery (BCS) have been reported and may be due to advanced stage at diagnosis. Our hypothesis was that low-income and ethnic minority patients have an increased tumor size at diagnosis and decreased likelihood of BCS. PATIENTS AND METHODS: A retrospective review was conducted of early stage breast cancer patients from 10 hospitals in Harris County, Texas, between 2004 and 2011. Clinical stage was calculated on the basis of data from the institutional tumor registries and electronic medical records. Zip code-based socioeconomic factors were downloaded from the US Census Bureau (http://www.census.gov/). Linear regression was used to identify predictors of tumor size, and logistic regression was used to identify predictors of BCS. RESULTS: The cohort included 3937 patients, comprising 2546 (65%) whites, 535 (14%) African Americans, 482 (11%) Hispanics, and 374 (10%) Asian/others. Multivariate linear regression demonstrated socioeconomic status (SES), younger age, African American, Hispanic race, and hormone receptor-negative tumors to be associated with increased tumor size at diagnosis (P < .05). Hispanic and Asian/other race, larger tumor size, combined estrogen receptor-negative/progesterone receptor-negative tumors were associated with not receiving BCS. CONCLUSION: Race and SES were both associated with larger tumor size at diagnosis. Larger tumor size, negative hormone receptor status, and Hispanic and Asian race were associated with lack of receipt of BCS. Breast cancer screening programs should target both minority and low SES groups. Rates of BCS should be interpreted cautiously when used as a quality metric because of the multiple factors, including tumor size and biology, contributing to its use.

How Should Surgical Residents Be Educated About Patient Safety: A Pilot Randomized Controlled Trial.

INTRODUCTION: The Accreditation Council for Graduate Medical Education mandates patient safety education without specific curricular guidelines. We hypothesized that a dedicated, adjunctive resident safety workshop (SW) led by surgical faculty compared with an online curriculum (OC) for hospital personnel alone would improve residents' patient safety perceptions and behaviors. MATERIALS AND METHODS: A pilot randomized controlled trial was performed from 2014 to 2015 within a university-based general surgery residency. Control and intervention groups, stratified by postgraduate year, participated in a hospital-based OC; the intervention group participated in an additional SW. Primary outcomes were perceptions of safety culture, teamwork, and speaking up as per the validated safety attitudes questionnaire (SAQ) at 6 and 12 months postintervention. Secondary outcomes included behavioral scores from blinded surgical faculty using the Oxford NonTechnical Skills scale. RESULTS: A total of 51 residents were enrolled (control = 25, intervention = 26). SAQ response rates were 100%, 100%, and 76% at baseline, 6 months, and 12 months, respectively. SAQ scores were similar at baseline between groups and did not change significantly at 6 or 12 months, independent of postgraduate year (PGY) level. Overall NonTechnical Skills scores were similar between groups, but senior residents (≥PGY 4) in the OC + SW group scored significantly higher in teamwork, decision-making, and situation awareness (all p < 0.05). CONCLUSION: An adjunctive, dedicated resident SW compared with a hospital-based OC alone did not significantly improve overall perceptions of patient safety. However, senior residents participating in the SW demonstrated improved patient safety perceptions and had significantly better intraoperative safety behaviors than senior residents in the OC group. Future curricular enhancements should include PGY-level specific education, iterative reviews, and increased faculty involvement. A larger randomized trial may be warranted.

Facilitators and barriers of implementing enhanced recovery in colorectal surgery at a safety net hospital: A provider and patient perspective.

BACKGROUND: Enhanced Recovery After Surgery (ERAS) pathways are known to decrease complications and duration of stay in colorectal surgery patients. However, it is unclear whether an ERAS pathway would be feasible and effective at a safety-net hospital. The aim of this study was to identify local barriers and facilitators before the adoption of an ERAS pathway for patients undergoing colorectal operations at a safety-net hospital. METHODS: Semistructured interviews were conducted to assess the perceived barriers and facilitators before ERAS adoption. Stratified purposive sampling was used. Interviews were audiotaped, transcribed verbatim, and analyzed using content analysis. Analytic and investigator triangulation were used to establish credibility. RESULTS: Interviewees included 8 anesthesiologists, 5 surgeons, 6 nurses, and 18 patients. Facilitators identified across the different medical professions were (1) feasibility and alignment with current practice, (2) standardization of care, (3) smallness of community, (4) good teamwork and communication, and (5) caring for patients. The barriers were (1) difficulty in adapting to change, (2) lack of coordination between different departments, (3) special needs of a highly comorbid and socioeconomically disadvantaged patient population, (4) limited resources, and (5) rotating residents. Facilitators identified by the patients were (1) welcoming a speedy recovery, (2) being well-cared for and satisfied with treatment, (3) adequate social support, (4) welcoming early mobilization, and (5) effective pain management. The barriers were (1) lack of quiet and private space, (2) need for more patient education and counseling, and (3) unforeseen complications. CONCLUSION: Although limited hospital resources are perceived as a barrier to ERAS implementation at a safety-net hospital, there is strong support for such pathways and multiple factors were identified that may facilitate change. Inclusion of patient perspectives is critical to identifying challenges and facilitators to implementing ERAS changes focused on optimizing patient perioperative health and outcomes.

Use of Computed Tomography in Diagnosing Ventral Hernia Recurrence: A Blinded, Prospective, Multispecialty Evaluation.

IMPORTANCE: Physical examination misses up to one-third of ventral hernia recurrences seen on radiologic imaging. However, tests such as computed tomographic (CT) imaging are subject to interpretation and require validation of interobserver reliability. OBJECTIVE: To determine the interobserver reliability of CT scans for detecting a ventral hernia recurrence among surgeons and radiologists. We hypothesized there would be significant disagreement in the diagnosis of a ventral hernia recurrence among different observers. Our secondary aim was to determine reasons for disagreement in the interpretation of CT scans. DESIGN, SETTING, AND PARTICIPANTS: One hundred patients who underwent ventral hernia repair from 2010-2011 at an academic health care center with a postoperative CT scan were randomly selected from a larger cohort. This study was conducted from July 2014 to March 2015. Prospective assessment of the presence or absence of a recurrent ventral hernia on CT scans was compared among 9 blinded reviewers and the radiology report. Five reviewers (consensus group) met to discuss all CT scans with disagreement. The discussion was assessed for keywords and key concepts. The remaining 4 reviewers (validation group) read the consensus group recommendations and reassessed the CT scans. Pre- and post-review κ were calculated; the post-review assessments were compared with clinical examination findings. MAIN OUTCOMES AND MEASURES: Interobserver reliability in determining hernia recurrence radiographically. RESULTS: Of 100 CT scans, there was disagreement among all 9 reviewers and the radiology report on the presence/absence of a ventral hernia in 73 cases (κ = 0.44; 95% CI, 0.35-0.54; P < .001). Following discussion among the consensus group, there remained disagreement in 10 cases (κ = 0.91; 95% CI, 0.83-0.95; P < .001). Among the validation group, the κ value had a slight improvement from 0.21 (95% CI, 0.12-0.33) to 0.34 (95% CI, 0.23-0.46) (P < .001) after reviewing the consensus group proposals. There was disagreement between clinical examination and the consensus group assessment of CT scans on the presence/absence of a ventral hernia in 25 cases. The concepts most frequently discussed were the absence of an accepted definition for a radiographic ventral hernia and differentiating pseudorecurrence from recurrence. CONCLUSIONS AND RELEVANCE: Owing to the high interobserver variability, CT scan was not associated with reliable diagnosing in ventral hernia recurrence. Consensus guidelines and improved communication between surgeon and radiologist may decrease interobserver variability.

Race not rural residency is predictive of surgical treatment for hepatocellular carcinoma: Analysis of the Texas Cancer Registry.

BACKGROUND AND OBJECTIVES: Rural patients have poor access to specialists and are less likely to receive evidence-based cancer care. We hypothesized that hepatocellular carcinoma (HCC) patients from rural counties in Texas would be less likely to receive surgical therapy than those from urban areas. METHODS: The Texas Cancer Registry was queried (2000-2008). County-level data included "rural or urban" designation and income variables derived by zip code. Surgical intervention included: (i) ablation, (ii) resection-partial or total lobectomy, or (iii) transplantation. A multinomial logistic regression was created to determine predictors of intervention. RESULTS: Five thousand thirty seven HCC patients were identified (86% urban) for study. A multinomial regression demonstrated, older age, African-American race, and lower income reduced the likelihood of ablation. Younger age, female gender, Caucasian, and Asian/other race predicted surgical resection, or transplantation. Hispanic race was associated with lower likelihood of resection (RRR 0.75) and transplantation (RRR 0.74), whereas African-American race was associated with pronounced decrease for transplantation (RRR 0.48). Area of residency was not predictive of intervention. CONCLUSIONS: Rural residency did not decrease the likelihood of surgical intervention for hepatocellular carcinoma. Race and income continue to be associated with significant treatment disparity. Additional investigation should focus on factors that govern the selection of resection or transplantation for potentially eligible patients.

Preoperative Glycosylated Hemoglobin and Postoperative Glucose Together Predict Major Complications after Abdominal Surgery.

BACKGROUND: Glycosylated hemoglobin (HbA1c) is diagnostic of and a measure of the quality of control of diabetes mellitus. Both HbA1c and perioperative hyperglycemia have been targeted as modifiable risk factors for postoperative complications. The HbA1c percent cutoff that best predicts major complications has not been defined. STUDY DESIGN: A prospective study of all abdominal operations from a single institution from 2007 to 2010 was performed. All patients with HbA1c within 3 months before surgery were included. The primary end point was major complication, using the Clavien-Dindo complication system, within 30 days of surgery. Stepwise, multivariate analysis was performed including clinically relevant variables chosen a priori. RESULTS: Among 438 patients who had a measured HbA1c, 96 (21.9%) experienced a major complication. On multivariate analysis, HbA1c ≥ 6.5% (odds ratio = 1.95; 95% CI, 1.17-3.24; p = 0.01) was found to be the most significant predictor of major complications. Glyosylated hemoglobin and glucose were strongly correlated (correlation coefficient 0.414, p < 0.01). Predicted probabilities demonstrated that both HbA1c and glucose together contributed to major complications; and HbA1c impacted the ability to achieve optimal perioperative glucose control. Patients with a BMI >30 kg/m(2), history of coronary artery disease, and nonwhite race were more likely to have a HbA1c ≥ 6.5%. CONCLUSIONS: Elevated HbA1c ≥ 6.5% and perioperative hyperglycemia were associated with an increased rate of major complications after abdominal surgery. Elevated peak postoperative glucose levels were correlated with elevated HbA1c and were independently associated with major complications. More liberal HbA1c testing should be considered in high-risk patients before elective surgery. Safe, feasible, and effective strategies to reduce both HbA1c and perioperative hyperglycemia need to be developed to optimize patient outcomes.

Alternative end points for trauma studies: A survey of academic trauma surgeons.

INTRODUCTION: Changing the epidemiology of trauma makes traditional end points like 30-day mortality less than ideal. Many alternative end points have been suggested; however, they are not yet accepted by the trauma community or regulatory bodies. This study characterizes opinions about the adequacy of accepted end points of studies of trauma and the appropriateness of several novel end points. METHODS: An electronic survey was administered to all members of the American Association for the Surgery of Trauma. Questions involved demographics, research experience, appropriateness of proposed study end points, and the role of nontraditional, surrogate, and composite end points. RESULTS: Response rate was 16% (141 of 873) with 74% of respondents practicing at Level 1 Trauma Centers. The respondents were very experienced, with 81% reporting >10 years of practice at the attending level and 87% actively involved in research. The majority of respondents rated the following end points favorably: 24-hour survival, 30-day survival, and time to control of acute hemorrhage with approval rates of 82%, 78%, and 76%, respectively. Six-hour survival, intensive care unit-free survival, and days free of multiorgan failure were rated as appropriate or very appropriate less than 66% of the time. Only 45% of respondents judged the currently used end points of trauma to be appropriate. More than 80% respondents disagreed or strongly disagreed that there was no role for of surrogate or composite endpoints in research of trauma resuscitation. CONCLUSION: There is strong interest in finding efficient end points in trauma research that are both specific and reflect the changing epidemiology of trauma death. The alternative end points of 24-hour survival and time to control of acute hemorrhage had similar approval rates to 30-day mortality.

Treatment delays of colon cancer in a safety-net hospital system.

BACKGROUND: Disparities in colon cancer survival have been reported to result from advanced stage at diagnosis and delayed therapy. We hypothesized that delays in treatment among medically underserved patients occur as a result of system-level barriers in a safety-net hospital system. MATERIALS AND METHODS: Retrospective review and analysis of colon cancer patients treated in a large safety-net hospital system between May 2008 and May 2012. Data were collected on demographics, stage at diagnosis, time to surgery, time to adjuvant chemotherapy, and vital status. Regression analyses were performed to determine predictors of delays and failure to receive therapy. RESULTS: Of 248 patients treated for colon cancer, 56% (n = 140) had advanced disease at the time of presentation; furthermore, 29.1% of all colectomies for colon cancer were performed on an urgent or emergent basis. Thirty-six patients with stage III and IV disease did not receive chemotherapy (26%). Race, age, gender, and hospice care did not predict receipt of chemotherapy or delays to treatment. Patients with stage I colon cancer had a significantly longer interval between diagnosis and elective surgery when compared with patients with stage II, III, and IV colon cancer, with only 10% (n = 3) undergoing resection sooner than 6 wk after diagnosis. CONCLUSIONS: One in three patients diagnosed with colon cancer in a large safety-net hospital system require urgent or emergent surgery, and one in two present with advanced disease. Reducing disparities should focus on earlier diagnosis of colon cancer and improving access to surgical specialists.