Perceived Implications of Compensation Structure for Academic Surgical Practice: A Qualitative Study.

This qualitative study examines how incentive-based and salary-only compensation models affect academic surgeons.

Barriers and Facilitators to Clinical Practice Development in Men and Women Surgeons.

Importance: Many early-career surgeons struggle to develop their clinical practices, leading to high rates of burnout and attrition. Furthermore, women in surgery receive fewer, less complex, and less remunerative referrals compared with men. An enhanced understanding of the social and structural barriers to optimal growth and equity in clinical practice development is fundamental to guiding interventions to support academic surgeons. Objective: To identify the barriers and facilitators to clinical practice development with attention to differences related to surgeon gender. Design, Setting, and Participants: A multi-institutional qualitative descriptive study was performed using semistructured interviews analyzed with a grounded theory approach. Interviews were conducted at 5 academic medical centers in the US between July 12, 2022, and January 31, 2023. Surgeons with at least 1 year of independent practice experience were selected using purposeful sampling to obtain a representative sample by gender, specialty, academic rank, and years of experience. Main Outcomes and Measures: Surgeon perspectives on external barriers and facilitators of clinical practice development and strategies to support practice development for new academic surgeons. Results: A total of 45 surgeons were interviewed (23 women [51%], 18 with ≤5 years of experience [40%], and 20 with ≥10 years of experience [44%]). Surgeons reported barriers and facilitators related to their colleagues, department, institution, and environment. Dominant themes for both genders were related to competition, case distribution among partners, resource allocation, and geographic market saturation. Women surgeons reported additional challenges related to gender-based discrimination (exclusion, questioning of expertise, role misidentification, salary disparities, and unequal resource allocation) and additional demands (related to appearance, self-advocacy, and nonoperative patient care). Gender concordance with patients and referring physicians was a facilitator of practice development for women. Surgeons suggested several strategies for their colleagues, department, and institution to improve practice development by amplifying facilitators and promoting objectivity and transparency in resource allocation and referrals. Conclusions and Relevance: The findings of this qualitative study suggest that a surgeon's external context has a substantial influence on their practice development. Academic institutions and departments of surgery may consider the influence of their structures and policies on early career surgeons to accelerate practice development and workplace equity.

Costs of Care for Operative and Nonoperative Management of Emergency General Surgery Conditions.

OBJECTIVE: Many emergency general surgery (EGS) conditions can be managed operatively or nonoperatively, with outcomes that vary by diagnosis. We hypothesized that operative management would lead to higher in-hospital costs but to cost savings over time. BACKGROUND: EGS conditions account for $28 billion in health care costs in the United States annually. Compared with scheduled surgery, patients who undergo emergency surgery are at increased risk of complications, readmissions, and death, with accompanying costs of care that are up to 50% higher than elective surgery. Our prior work demonstrated that operative management had variable impacts on clinical outcomes depending on the EGS condition. METHODS: This was a nationwide, retrospective study using fee-for-service Medicare claims data. We included patients 65.5 years of age or older with a principal diagnosis for an EGS condition 7/1/2015-6/30/2018. EGS conditions were categorized as: colorectal, general abdominal, hepatopancreaticobiliary (HPB), intestinal obstruction, and upper gastrointestinal. We used near-far matching with a preference-based instrumental variable to adjust for confounding and selection bias. Outcomes included Medicare payments for the index hospitalization and at 30, 90, and 180 days. RESULTS: Of 507,677 patients, 30.6% received an operation. For HPB conditions, costs for operative management were initially higher but became equivalent at 90 and 180 days. For all others, operative management was associated with higher inpatient costs, which persisted, though narrowed, over time. Out-of-pocket costs were nearly equivalent for operative and nonoperative management. CONCLUSIONS: Compared with nonoperative management, costs were higher or equivalent for operative management of EGS conditions through 180 days, which could impact decision-making for clinicians, patients, and health systems in situations where clinical outcomes are similar.

Conditional Effects of Race on Operative and Nonoperative Outcomes of Emergency General Surgery Conditions.

INTRODUCTION: Many emergency general surgery (EGS) conditions can be managed both operatively or nonoperatively; however, it is unknown whether the decision to operate affects Black and White patients differentially. METHODS: We identified a nationwide cohort of Black and White Medicare beneficiaries, hospitalized for common EGS conditions from July 2015 to June 2018. Using near-far matching to adjust for measurable confounding and an instrumental variable analysis to control for selection bias associated with treatment assignment, we compare outcomes of operative and nonoperative management in a stratified population of Black and White patients. Outcomes included in-hospital mortality, 30-day mortality, nonroutine discharge, and 30-day readmissions. An interaction test based on a t test was used to determine the conditional effects of operative versus nonoperative management between Black and White patients. RESULTS: A total of 556,087 patients met inclusion criteria, of which 59,519 (10.7%) were Black and 496,568 (89.3%) were White. Overall, 165,932 (29.8%) patients had an operation and 390,155 (70.2%) were managed nonoperatively. Significant outcome differences were seen between operative and nonoperative management for some conditions; however, no significant differences were seen for the conditional effect of race on outcomes. CONCLUSIONS: The decision to manage an EGS patient operatively versus nonoperatively has varying effects on surgical outcomes. These effects vary by EGS condition. There were no significant conditional effects of race on the outcomes of operative versus nonoperative management among universally insured older adults hospitalized with EGS conditions.

A Novel Mobile App to Identify Patients With Multimorbidity in the Emergency Setting: Development of an App and Feasibility Trial.

BACKGROUND: Multimorbidity is associated with an increased risk of poor surgical outcomes among older adults; however, identifying multimorbidity in the clinical setting can be a challenge. OBJECTIVE: We created the Multimorbid Patient Identifier App (MMApp) to easily identify patients with multimorbidity identified by the presence of a Qualifying Comorbidity Set and tested its feasibility for use in future clinical research, validation, and eventually to guide clinical decision-making. METHODS: We adapted the Qualifying Comorbidity Sets' claims-based definition of multimorbidity for clinical use through a modified Delphi approach and developed MMApp. A total of 10 residents input 5 hypothetical emergency general surgery patient scenarios, common among older adults, into the MMApp and examined MMApp test characteristics for a total of 50 trials. For MMApp, comorbidities selected for each scenario were recorded, along with the number of comorbidities correctly chosen, incorrectly chosen, and missed for each scenario. The sensitivity and specificity of identifying a patient as multimorbid using MMApp were calculated using composite data from all scenarios. To assess model feasibility, we compared the mean task completion by scenario to that of the American College of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator (ACS-NSQIP-SRC) using paired t tests. Usability and satisfaction with MMApp were assessed using an 18-item questionnaire administered immediately after completing all 5 scenarios. RESULTS: There was no significant difference in the task completion time between the MMApp and the ACS-NSQIP-SRC for scenarios A (86.3 seconds vs 74.3 seconds, P=.85) or C (58.4 seconds vs 68.9 seconds,P=.064), MMapp took less time for scenarios B (76.1 seconds vs 87.4 seconds, P=.03) and E (20.7 seconds vs 73 seconds, P<.001), and more time for scenario D (78.8 seconds vs 58.5 seconds, P=.02). The MMApp identified multimorbidity with 96.7% (29/30) sensitivity and 95% (19/20) specificity. User feedback was positive regarding MMApp's usability, efficiency, and usefulness. CONCLUSIONS: The MMApp identified multimorbidity with high sensitivity and specificity and did not require significantly more time to complete than a commonly used web-based risk-stratification tool for most scenarios. Mean user times were well under 2 minutes. Feedback was overall positive from residents regarding the usability and usefulness of this app, even in the emergency general surgery setting. It would be feasible to use MMApp to identify patients with multimorbidity in the emergency general surgery setting for validation, research, and eventual clinical use. This type of mobile app could serve as a template for other research teams to create a tool to easily screen participants for potential enrollment.

National Cohort Study of Resource Utilization in Older Adults With Emergency General Surgery Conditions.

INTRODUCTION: Prior studies have sought to describe Emergency General Surgery (EGS) burden, but a detailed description of resource utilization for both operative and nonoperative management of EGS conditions has not been undertaken. METHODS: Patient and hospital characteristics were extracted from Medicare data, 2015-2018. Operations, nonsurgical procedures, and other resources (i.e., radiology) were defined using Current Procedural Terminology codes. RESULTS: One million eight hundred two thousand five hundred forty-five patients were included in the cohort. The mean age was 74.7 y and the most common diagnoses were upper gastrointestinal. The majority of hospitals were metropolitan (75.1%). Therapeutic radiology services were available in 78.4% of hospitals and operating rooms or endoscopy suites were available in 92.5% of hospitals. There was variability in resource utilization across EGS subconditions, with hepatobiliary (26.4%) and obstruction (23.9%) patients most frequently undergoing operation. CONCLUSIONS: Treatment of EGS diseases in older adults involves several interventional resources. Changes in EGS models, acute care surgery training, and interhospital care coordination may be beneficial to the treatment of EGS patients.

Barriers and facilitators to surgical access in underinsured and immigrant populations.

BACKGROUND: Marginalized communities are at risk of receiving inequitable access to surgical care. We aimed to examine the barriers and facilitators to access to surgery in underinsured and immigrant populations. METHODS: A systematic review of disparities in access to surgical care was performed between January 1, 2000-March 2, 2022. Methodological quality was assessed with the Mixed Methods Appraisal Tool. A convergent integrated approach was used to code common themes between studies. RESULTS: Of 1315 publications, a total of 66 studies were included for systematic review. Eight studies specifically discussed immigrant patient populations. Barriers and facilitators to surgical access were categorized by patient and health systems related factors. CONCLUSIONS: Established facilitators to improve surgical access are centered on patient-level factors while interventions to address systems-related barriers are limited and may be an area for further investigation. Research focused on access to surgery in immigrant populations remains sparse.

Factors Associated With Primary Care Physician Decision-making When Making Medication Recommendations vs Surgical Referrals.

Importance: Although objective data are used routinely in prescription drug recommendations, it is unclear how referring physicians apply evidence when making surgeon or hospital recommendations for surgery. Objective: To compare the factors associated with the hospital or surgeon referral decision-making process with that used for prescription medication recommendations. Design, Setting, and Participants: This qualitative study comprised interviews conducted between April 26 and May 18, 2021, of a purposive sample of 21 primary care physicians from a large primary care network in the Northeast US. Main Outcomes and Measures: Main outcomes were the factors considered when making prescription medication recommendations vs referral recommendations to specific surgeons or hospitals for surgery. Results: All 21 participant primary care physicians (14 women [66.7%]) reported use of evidence-based decision support tools and patient attributes for prescription medication recommendations. In contrast, for surgeon and hospital referral recommendations, primary care physicians relied on professional experience and training, personal beliefs about surgical quality, and perceived convenience. Primary care physicians cited perceived limitations of existing data on surgical quality as a barrier to the use of such data in the process of making surgical referrals. Conclusions and Relevance: As opposed to the widespread use of objective decision support tools for guidance on medication recommendations, primary care physicians relied on subjective factors when making referrals to specific surgeons and hospitals. The findings of this study highlight the potential to improve surgical outcomes by introducing accessible, reliable data as an imperative step in the surgical referral process.

Examining disparities among older multimorbid emergency general surgery patients: An observational study of Medicare beneficiaries.

BACKGROUND: Qualifying comorbidity sets (QCS) are tools used to identify multimorbid patients at increased surgical risk. It is unknown how the QCS framework for multimorbidity affects surgical risk in different racial groups. METHODS: This retrospective cohort study included Medicare patients age ≥65.5 who underwent an emergency general surgery operation from 2015 to 2018. Our exposure was race and multimorbidity, included in our model as an interaction term. The primary outcome of the study was 30-day mortality. Secondary outcomes included routine discharge, 30-day readmission, length of stay, and complications. RESULTS: In total, 163,148 patients who underwent and operation were included in this study. Of these, 13,852 (8.5%, p < 0.001) were Black, and 149,296 (91.5%, p < 0.001) were White. Black multimorbid patients had no significant differences in 30-day mortality, routine discharge or 30-day readmission when compared to White multimorbid patients after risk-adjustment. Black multimorbid patients had significantly lower odds of complications (OR 0.89, p = 0.014) compared to White multimorbid patients. CONCLUSIONS: Our study of universally insured patients highlights the critical role of pre-operative health status and its association with surgical outcomes.

Rates of Surgical Consultations After Emergency Department Admission in Black and White Medicare Patients.

Importance: A surgical consultation is a critical first step in the care of patients with emergency general surgery conditions. It is unknown if Black Medicare patients and White Medicare patients receive surgical consultations at similar rates when they are admitted from the emergency department. Objective: To determine whether Black Medicare patients have similar rates of surgical consultations when compared with White Medicare patients after being admitted from the emergency department with an emergency general surgery condition. Design, Setting, and Participants: This was a retrospective cohort study that took place at US hospitals with an emergency department and used a computational generalization of inverse propensity score weight to create patient populations with similar covariate distributions. Participants were Medicare patients age 65.5 years or older admitted from the emergency department for an emergency general surgery condition between July 1, 2015, and June 30, 2018. The analysis was performed during February 2022. Patients were classified into 1 of 5 emergency general surgery condition categories based on principal diagnosis codes: colorectal, general abdominal, hepatopancreatobiliary, intestinal obstruction, and upper gastrointestinal. Exposures: Black vs White race. Main Outcomes and Measures: Receipt of a surgical consultation after admission from the emergency department with an emergency general surgery condition. Results: A total of 1 686 940 patients were included in the study. Of those included, 214 788 patients were Black (12.7%) and 1 472 152 patients were White (87.3%). After standardizing for medical and diagnostic imaging covariates, Black patients had 14% lower odds of receiving a surgical consultation (odds ratio [OR], 0.86; 95% CI, 0.85-0.87) with a risk difference of -3.17 (95% CI, -3.41 to -2.92). After standardizing for socioeconomic covariates, Black patients remained at an 11% lower odds of receiving a surgical consultation compared with similar White patients (OR, 0.89; 95% CI, 0.88-0.90) with a risk difference of -2.49 (95% CI, -2.75 to -2.23). Additionally, when restricting the analysis to Black patients and White patients who were treated in the same hospitals, Black patients had 8% lower odds of receiving a surgical consultation when compared with White patients (OR, 0.92; 95% CI, 0.90-0.93) with a risk difference of -1.82 (95% CI, -2.18 to -1.46). Conclusions and Relevance: In this study, Black Medicare patients had lower odds of receiving a surgical consultation after being admitted from the emergency department with an emergency general surgery condition when compared with similar White Medicare patients. These disparities in consultation rates cannot be fully attributed to medical comorbidities, insurance status, socioeconomic factors, or individual hospital-level effects.

Colorectal cancer disparities across the continuum of cancer care: A systematic review and meta-analysis.

BACKGROUND: Disparate colorectal cancer outcomes persist in vulnerable populations. We aimed to examine the distribution of research across the colorectal cancer care continuum, and to determine disparities in the utilization of Surgery among Black patients. METHODS: A systematic review and meta-analysis of colorectal cancer disparities studies was performed. The meta-analysis assessed three utilization measures in Surgery. RESULTS: Of 1,199 publications, 60% focused on Prevention, Screening, or Diagnosis, 20% on Survivorship, 15% on Treatment, and 1% on End-of-Life Care. A total of 16 studies, including 1,110,674 patients, were applied to three meta-analyses regarding utilization of Surgery. Black patients were less likely to receive surgery, twice as likely to refuse surgery, and less likely to receive laparoscopic surgery, when compared to White patients. CONCLUSIONS: Since 2011, the majority of research focused on prevention, screening, or diagnosis. Given the observed treatment disparities among Black patients, future efforts to reduce colorectal cancer disparities should include interventions within Surgery.

Trainee Sex and Accreditation Council for Graduate Medical Education Milestone Assessments During General Surgery Residency.

Importance: In evaluating the effectiveness of general surgery (GS) training, an unbiased assessment of the progression of residents with attention to individual learner factors is imperative. Objective: To evaluate the role of trainee sex in milestone achievement over the course of GS residency using national data from the Accreditation Council for Graduate Medical Education (ACGME). Design, Setting, and Participants: This cross-sectional study evaluated female and male GS residents enrolled in ACGME-accredited programs in the US from 2014 to 2018 with reported variation in milestones performance across years in training and representation. Data were analyzed from November 2019 to June 2021. Main Outcomes and Measures: Mean reported milestone score at initial and final assessment, and predicted time-to-attainment of equivalent performance by sex. Results: Among 4476 GS residents from 250 programs who had milestone assessments at any point in their clinical training, 1735 were female (38.8%). Initially, female and male residents received similar mean (SD) milestone scores (1.95 [0.50] vs 1.94 [0.50]; P = .69). At the final assessment, female trainees received overall lower mean milestone scores than male trainees (4.25 vs 4.31; P < .001). Significantly lower mean milestone scores were reported for female residents at the final assessment for several subcompetencies in both univariate and multivariate analyses, with only medical knowledge 1 (pathophysiology, diagnosis, and initial management) common to both. Multilevel mixed-effects linear modeling demonstrated that female trainees had significantly lower rates of monthly milestone attainment in the subcompetency of medical knowledge 1, which was associated with a significant difference in training time of approximately 1.8 months. Conclusions and Relevance: Both female and male GS trainees achieved the competency scores necessary to transition to independence after residency as measured by the milestones assessment system. Initially, there were no sex differences in milestone score. By graduation, there were differences in the measured assessment of female and male trainees across several subcompetencies. Careful monitoring for sex bias in the evaluation of trainees and scrutiny of the training process is needed to ensure that surgical residency programs support the educational needs of both female and male trainees.