Identifying Population-Level and Within-Hospital Disparities in Surgical Care.

INTRODUCTION: The lack of consensus on equity measurement and its incorporation into quality-assessment programs at the hospital and system levels may be a barrier to addressing disparities in surgical care. This study aimed to identify population-level and within-hospital differences in the quality of surgical care provision. METHODS: The analysis included 657 National Surgical Quality Improvement Program participating hospitals with over 4 million patients (2014-2018). Multi-level random slope, random intercept modeling was used to examine for population-level and in-hospital disparities. Disparities in surgical care by Area Deprivation Index (ADI), race, and ethnicity were analyzed for five measures: all-case inpatient mortality, all-case urgent readmission, all-case postoperative surgical site infection, colectomy mortality, and spine surgery complications. RESULTS: Population-level disparities were identified across all measures by ADI, two measures for Black race (all-case readmissions and spine surgery complications), and none for Hispanic ethnicity. Disparities remained significant in the adjusted models. Prior to risk-adjustment, in all measures examined, within-hospital disparities were detected in: 25.8-99.8% of hospitals for ADI, 0-6.1% of hospitals for Black race, and 0-0.8% of hospitals for Hispanic ethnicity. Following risk-adjustment, in all measures examined, fewer than 1.1% of hospitals demonstrated disparities by ADI, race, or ethnicity. CONCLUSIONS: Following risk adjustment, very few hospitals demonstrated significant disparities in care. Disparities were more frequently detected by ADI than by race and ethnicity. The lack of substantial in-hospital disparities may be due to the use of postoperative metrics, small sample sizes, the risk adjustment methodology, and healthcare segregation. Further work should examine surgical access and healthcare segregation.

Management & surveillance of rectal neuroendocrine tumours: a single-centre retrospective analysis.

BACKGROUND: Rectal neuroendocrine tumours (rNETs) are rare but are increasing in incidence. Current management and surveillance recommendations are based on low-grade evidence. Follow-up practices are often inconsistent and costly. This retrospective study analyses a single-centre's experience with rNETs to assess incidence, management practices, outcomes, and guideline adherence. METHODS: This is a single-centre retrospective study from Queensland Australia, spanning from 2012 to 2023. Twenty-eight rNET cases met inclusion criteria. Examined parameters included incidence, management, outcomes and adherence to European Neuroendocrine Tumour Society (ENETS) guidelines. R1 resection rate was analysed for associations with resection technique and lesion recognition and recurrence rate was assessed in all patients. RESULTS: This study shows an increasing incidence of rNETs during the study period, reflecting a global trend. R1 resection rate at initial endoscopy was 75%. There was a general lack of advanced endoscopic techniques utilized and poor lesion recognition, however a statistically significant correlation was not established between these factors and an R1 result (P < 0.05). Most patients with an R1 result had subsequent re-resection to render the result R0, however five patients (33%) underwent surveillance with no reports of recurrence on follow-up. Overall, follow-up practices in our cohort were inconsistent and did not adhere to guidelines. CONCLUSION: rNETs are increasing in incidence, emphasizing the need for standardized management and surveillance. Further training is required for rNET recognition and advanced endoscopic resection techniques. Further research is required to assess long-term outcomes in surveilled R1 cases, understand optimal endoscopic resection techniques and further develop local surveillance guidelines.

Development and Validation of a Novel Literature-Based Method to Identify Disparity-Sensitive Surgical Quality Metrics.

BACKGROUND: Disparity in surgical care impedes the delivery of uniformly high-quality care. Metrics that quantify disparity in care can help identify areas for needed intervention. A literature-based Disparity-Sensitive Score (DSS) system for surgical care was adapted by the Metrics for Equitable Access and Care in Surgery (MEASUR) group. The alignment between the MEASUR DSS and Delphi ratings of an expert advisory panel (EAP) regarding the disparity sensitivity of surgical quality metrics was assessed. STUDY DESIGN: Using DSS criteria MEASUR co-investigators scored 534 surgical metrics which were subsequently rated by the EAP. All scores were converted to a 9-point scale. Agreement between the new measurement technique (ie DSS) and an established subjective technique (ie importance and validity ratings) were assessed using the Bland-Altman method, adjusting for the linear relationship between the paired difference and the paired average. The limit of agreement (LOA) was set at 1.96 SD (95%). RESULTS: The percentage of DSS scores inside the LOA was 96.8% (LOA, 0.02 points) for the importance rating and 94.6% (LOA, 1.5 points) for the validity rating. In comparison, 94.4% of the 2 subjective EAP ratings were inside the LOA (0.7 points). CONCLUSIONS: Applying the MEASUR DSS criteria using available literature allowed for identification of disparity-sensitive surgical metrics. The results suggest that this literature-based method of selecting quality metrics may be comparable to more complex consensus-based Delphi methods. In fields with robust literature, literature-based composite scores may be used to select quality metrics rather than assembling consensus panels.

Disparity-Sensitive Measures in Surgical Care: A Delphi Panel Consensus.

BACKGROUND: In the US, disparities in surgical care impede the delivery of uniformly high-quality care to all patients. There is a lack of disparity-sensitive measures related to surgical care. The American College of Surgeons Metrics for Equitable Access and Care in Surgery group, through research and expert consensus, aimed to identify disparity-sensitive measures in surgical care. STUDY DESIGN: An environmental scan, systematic literature review, and subspecialty society surveys were conducted to identify potential disparity-sensitive surgical measures. A modified Delphi process was conducted where panelists rated measures on both importance and validity. In addition, a novel literature-based disparity-sensitive scoring process was used. RESULTS: We identified 841 potential disparity-sensitive surgical measures. From these, our Delphi and literature-based approaches yielded a consensus list of 125 candidate disparity-sensitive measures. These measures were rated as both valid and important and were supported by the existing literature. CONCLUSION: There are profound disparities in surgical care within the US healthcare system. A multidisciplinary Delphi panel identified 125 potential disparity-sensitive surgical measures that could be used to track health disparities, evaluate the impact of focused interventions, and reduce healthcare inequity.

Socioeconomic disparities in rates of facial fracture surgeries for women and men at a regional tertiary care centre in Australia.

BACKGROUND: Assault is the most common mechanism of injury in patients presenting with facial trauma in Australia. For women, there is a propensity for maxillofacial injuries to stem from intimate partner violence (IPV). Those with a low socioeconomic status have higher rates of IPV. This study examines variations in the proportion of surgical procedures that are due to facial trauma for Australian women and men by employment status and residential socioeconomic status. METHODS: A single centre retrospective study was conducted (2008-2018). The proportion of operative patients presenting with facial fractures was examined. Multivariable logistic regression adjusting for year and age, was performed for women and men. RESULTS: Facial fractures comprised 1.51% (1602) of all surgeries, patients had a mean age of 32, and 81.3% were male. Unemployed patients were more likely to require surgery for a facial fracture (OR 2.36 (2.09-2.68), P <0.001), and there were no significant variations by index of economic resources (IER). Unemployed males had higher rates of facial fractures (OR 2.09 (1.82-2.39), P <0.001). Unemployed and disadvantaged IER females had higher rates of facial fractures (OR 5.02 (3.73-6.75), P <0.001 and OR 2.31(1.63-3.29), P <0.001). CONCLUSIONS: This study found disparities in rates of surgery for facial fractures; unemployment increased the rates for men and women, whereas disadvantaged IER increased rates for women. Studies have demonstrated higher rates of IPV for unemployed and low socioeconomic status women. Further research ascertaining the aetiology of these disparities is important both for primary prevention initiatives and to enable treating clinicians to better understand and address the role of IPV and alcohol consumption in these injuries.

Disparities in surgical outcomes for low socioeconomic status patients in Australia.

BACKGROUND: There are disparities in surgical outcomes for patients of low socioeconomic status globally, including in countries with universal healthcare systems. There is limited data on the impact of low socioeconomic status on surgical outcomes in Australia. This study examines surgical outcomes by both self-reported unemployment and neighbourhood level socioeconomic status in Australia. METHODS: A retrospective administrative data review was conducted at a tertiary care centre over a 10-year period (2008-2018) including all adult surgical patients. Multivariable logistic regression adjusting for year, age, sex and Charlson Comorbidity Index was performed. RESULTS: 106 197 patients underwent a surgical procedure in the decade examined. The overall adverse event rates were mortality (1.13%), total postoperative complications (10.9%), failure to rescue (0.75%) and return to theatre (4.31%). Following multivariable testing, unemployed and low socioeconomic patients had a higher risk of postoperative mortality (OR 2.06 (1.50-2.82), OR 1.37 (1.15-1.64)), all complications (OR 1.43 (1.31-1.56), OR 1.21 (1.14-1.28)), failure to rescue (OR 2.03 (1.39-2.95), OR 1.38 (1.11-1.72)) and return to theatre (OR 1.42 (1.27-1.59), OR 1.24 (1.14-1.36)) (P < 0.005 for all). CONCLUSIONS: Despite universal healthcare, there are disparities in surgical adverse events for patients of low socioeconomic status in Australia. Disparities in surgical outcomes can stem from three facets: a patient's access to healthcare (the severity of disease at the time of presentation), variation in perioperative care delivery, and social determinants of health. Further work is required to pinpoint why these disparities are present and to evaluate the impact of strategies that aim to reduce disparities.

Disparities in Advanced Peripheral Arterial Disease Presentation by Socioeconomic Status.

BACKGROUND: Diabetes and peripheral arterial disease (PAD) often synergistically lead to foot ulceration, infection, and gangrene, which may require lower limb amputation. Worldwide there are disparities in the rates of advanced presentation of PAD for vulnerable populations. This study examined rates of advanced presentations of PAD for unemployed patients, those residing in low Index of Economic Resources (IER) areas, and those in rural areas of Australia. METHODS: A retrospective study was conducted at a regional tertiary care centre (2008-2018). To capture advanced presentations of PAD, the proportion of operative patients presenting with complications (gangrene/ulcers), the proportion of surgeries that are amputations, and the rate of emergency to elective surgeries were examined. Multivariable logistic regression adjusting for year, age, sex, Charlson Comorbidity Index, and sociodemographic variables was performed. RESULTS: In the period examined, 1115 patients underwent a surgical procedure for PAD. Forty-nine per cent of patients had diabetes. Following multivariable testing, the rates of those requiring amputations were higher for unemployed (OR 1.99(1.05-3.79), p = 0.036) and rural patients (OR 1.83(1.21-2.76), p = 0.004). The rate of presentation with complications was higher for unemployed (OR 7.2(2.13-24.3), p = 0.001), disadvantaged IER (OR 1.91(1.2-3.04), p = 0.007), and rural patients (OR 1.73(1.13-2.65), p = 0.012). The rate of emergency to elective surgery was higher for unemployed (OR 2.32(1.18-4.54), p = 0.015) and rural patients (OR 1.92(1.29-2.86), p = 0.001). CONCLUSIONS: This study found disparities in metrics capturing delayed presentations of PAD: higher rates of presentations with complications, higher amputation rates, and increased rates of emergency to elective surgery, for patients of low socioeconomic status and those residing in rural areas. This suggests barriers to appropriate, effective, and timely care exists for these patients.

Emergency to Elective Surgery Ratio as a Disparities Sensitive Surgical Access Metric, A Study of Low Socioeconomic Status in Australia.

BACKGROUND: The emergency to elective surgery ratio is a proposed indicator for global access to surgical care. There is a well-established link between low socioeconomic status and increased morbidity and mortality. This study examined the emergency to elective surgery ratios for low socioeconomic patients utilising both self-reported unemployment and the neighbourhood Index of Economic Resources (IER). METHODS: A retrospective study was conducted at a regional tertiary care centre in Australia, including data over a ten-year period (2008-2018). Multivariable logistic regression adjusting for year, age, sex, Charlson Comorbidity Index, rurality, and if surgeries were due to trauma or injuries, was performed. RESULTS: 84,014 patients underwent a surgical procedure in the period examined; 29.0% underwent emergency surgery, 5.31% were unemployed, and 26.6% lived in neighbourhoods with the lowest IER. Following multivariable testing, the rate of emergency surgery was higher for unemployed patients (OR 1.42 [1.32-1.52], p < 0.001), and for those from the lowest IER (OR 1.13 [1.08-1.19], p < 0.001). For unemployed patients, this disparity increased during the study period (OR 1.32 [2008-2012], OR 1.48 [2013-2018]). When stratified by specialty, most (7/11) had significant disparities for unemployed patients: Cardiac/Cardiothoracic, Otolaryngology, Maxillofacial/Dental, Obstetrics/Gynaecology, Orthopaedics, Plastics, and Vascular surgery. CONCLUSIONS: Unemployed Australians and those residing in the most disadvantaged IER neighbourhoods had higher emergency to elective surgery rates. The disparity in emergency to elective surgery rates for unemployed patients was found in most surgical specialties and increased over the period examined. This suggests a widespread and potentially increasing disparity in access to surgical care for patients of socioeconomic disadvantage, specifically for those who are unemployed.

Surgical Services for Breast Cancer Patients in Australia, is There a Gap for Aboriginal and/or Torres Strait Islander Women?

BACKGROUND: Breast cancer is the most commonly diagnosed cancer in Aboriginal and/or Torres Strait Islander women. When compared to other Australians, Aboriginal and/or Torres Strait Islander women have a higher breast cancer mortality rate. This systematic literature review examined disparities in breast cancer surgical access and outcomes for Aboriginal and/or Torres Strait Islander women. METHODS: This systematic literature review, following the PRISMA guidelines, compared measures of breast cancer surgical care for Aboriginal and/or Torres Strait Islander people and other Australians. RESULTS: The 13 included studies were largely state-based retrospective reviews of data collected prior to the year 2012. Eight studies reported more advanced breast cancer presentation among Aboriginal and/or Torres Strait Islander women. Despite the increased distance to a multidisciplinary, specialist team, there were no disparities in seeing a surgeon, or in the time from diagnosis to surgical treatment. Two studies reported disparities in the receipt of surgery and two reported no variations. Three studies reported disparities in the receipt of mastectomy versus breast conserving surgery, whilst four studies reported no variations. No studies examined postoperative surgical outcomes. CONCLUSIONS: Aboriginal and/or Torres Strait Islander women present with more advanced breast cancer. There may be disparities in the receipt of surgery and the type of surgery. However, the metrics tested were not related to optimal care guidelines, and the databases utilised contain limited data on individual factors contributing to surgical care decisions. It is therefore difficult to determine whether the reported differences in the receipt of surgical care reflect disparate or appropriate care.

Patient-reported Outcomes at 6 to 12 Months Among Survivors of Firearm Injury in the United States.

OBJECTIVE: Assess outcomes in survivors of firearm injuries after 6 to 12 months and compared them with a similarly injured trauma population. BACKGROUND: For every individual in the United States who died of a firearm injury in 2017, three survived, living with the burden of their injury. Current firearm research largely focuses on mortality and short-term health outcomes, while neglecting the long-term consequences. METHODS: We contacted adult patients with a moderate-to-severe injury from a firearm or motor vehicle crash (MVC) treated at 3 level I trauma centers in Boston between 2015 and 2018. Patients were contacted 6 to 12 months postinjury to measure: presence of daily pain; screening for post-traumatic stress disorder (PTSD); new functional limitations; return to work; and physical and mental health-related quality of life. We matched each firearm injury patient to MVC patients using Coarsened Exact Matching. Adjusted Generalized Linear Models were used to compare matched patients. RESULTS: Of 177 eligible firearm injury survivors, 100 were successfully contacted and 63 completed the study. Among them, 67.7% reported daily pain, 53.2% screened positive for PTSD, 38.7% reported a new functional limitation in an activity of daily living, and 59.1% have not returned to work. Compared with population norms, overall physical and mental health-related quality of life was significantly reduced among firearm injury survivors. Compared with matched MVC survivors (n = 255), firearm injury survivors were significantly more likely to have daily pain [adjusted odds ratio (OR) 2.30, 95% confidence interval (CI) 1.08-4.87], to screen positive for PTSD (adjusted OR 3.06, 95% CI 1.42-6.58), and had significantly worse physical and mental health-related quality of life. CONCLUSIONS: This study highlights the need for targeted long-term follow-up care, physical rehabilitation, mental health screening, and interventions for survivors of firearm violence.

Defining a Research Agenda for Layperson Prehospital Hemorrhage Control: A Consensus Statement.

Importance: Trauma is the leading cause of death for US individuals younger than 45 years, and uncontrolled hemorrhage is a major cause of trauma mortality. The US military's medical advancements in the field of prehospital hemorrhage control have reduced battlefield mortality by 44%. However, despite support from many national health care organizations, no integrated approach to research has been made regarding implementation, epidemiology, education, and logistics of prehospital hemorrhage control by layperson immediate responders in the civilian sector. Objective: To create a national research agenda to help guide future work for prehospital hemorrhage control by laypersons. Evidence Review: The 2-day, in-person, National Stop the Bleed (STB) Research Consensus Conference was conducted on February 27 to 28, 2019, to identify and achieve consensus on research gaps. Participants included (1) subject matter experts, (2) professional society-designated leaders, (3) representatives from the federal government, and (4) representatives from private foundations. Before the conference, participants were provided a scoping review on layperson prehospital hemorrhage control. A 3-round modified Delphi consensus process was conducted to determine high-priority research questions. The top items, with median rating of 8 or more on a Likert scale of 1 to 9 points, were identified and became part of the national STB research agenda. Findings: Forty-five participants attended the conference. In round 1, participants submitted 487 research questions. After deduplication and sorting, 162 questions remained across 5 a priori-defined themes. Two subsequent rounds of rating generated consensus on 113 high-priority, 27 uncertain-priority, and 22 low-priority questions. The final prioritized research agenda included the top 24 questions, including 8 for epidemiology and effectiveness, 4 for materials, 9 for education, 2 for global health, and 1 for health policy. Conclusions and Relevance: The National STB Research Consensus Conference identified and prioritized a national research agenda to support laypersons in reducing preventable deaths due to life-threatening hemorrhage. Investigators and funding agencies can use this agenda to guide their future work and funding priorities.

The Association of State Firearm Legislation With the Burden of Firearm-Related Surgery.

BACKGROUND: United States state-level firearm legislation is linked to rates of firearm-related suicides, pediatric injuries, nonfatal injuries, hospital discharges, and mortality. Our objective was to evaluate the burden of firearm-related injuries requiring surgery for states with strict as opposed to nonstrict firearm legislation. MATERIALS AND METHODS: The 2014 Healthcare Cost and Utilization Project State Inpatient Database was utilized to extract data for all available 28 states and the District of Columbia. States were dichotomized into strict and nonstrict legislative categories using the 2014 Brady and Gifford's scores (15 strict, 14 nonstrict). Patients with a firearm injury requiring surgery were identified and the incidence of surgery aggregated to the county level. Negative binomial regression with an offset for county-level residential population was used to estimate the incident rate ratio for surgical volume comparing counties in strict and nonstrict states. Models were stratified by injury intent and adjusted for county population characteristics. RESULTS: A total of 11,939 patients were hospitalized with firearm-related injuries, with 65% (n = 7759) undergoing an operative procedure. The adjusted incidence rate of firearm-related surgery per 100,000 people was 1.29 (95% confidence interval; 1.13-1.46, P < 0.001) times higher and the adjusted cost of hospitalization per 100,000 people was $6028.69 ($3744.61-$8312.78, P = 0.001) greater for counties in nonstrict states than those for counties in strict states. The burden of health care for these injuries is invariably shifted to state- and county-level finances. CONCLUSIONS: The rate of firearm-related surgical intervention was higher for states with nonstrict firearm legislation than that for states with strict legislation. States should reevaluate their firearm legislation to potentially reduce the burden of firearm-related surgery and health care costs.

The Impact of Income on Emergency General Surgery Outcomes in Urban and Rural Areas.

BACKGROUND: Emergency general surgery (EGS) accounts for more than 2 million U.S. hospital admissions annually. Low-income EGS patients have higher rates of postoperative adverse events (AEs) than high-income patients. This may be related to health care segregation (a disparity in access to high-quality centers). The emergent nature of EGS conditions and the limited number of EGS providers in rural areas may result in less health care segregation and thereby less variability in EGS outcomes in rural areas. The objective of this study was to assess the impact of income on AEs for both rural and urban EGS patients. MATERIALS AND METHODS: The National Inpatient Sample (2007-2014) was queried for patients receiving one of 10 common EGS procedures. Multivariate regression models stratified by income quartiles in urban and rural cohorts adjusting for sociodemographic, clinical, and other hospital-based factors were used to determine the rates of surgical AEs (mortality, complications, and failure to rescue [FTR]). RESULTS: 1,687,088 EGS patients were identified; 16.60% (n = 280,034) of them were rural. In the urban cohort, lower income quartiles were associated with higher odds of AEs (mortality OR, 1.21 [95% CI, 1.15-1.27], complications, 1.07 [1.06-1.09]; FTR, 1.17 [1.10-1.24] P < 0.001). In the rural context, income quartiles were not associated with the higher odds of AE (mortality OR, 1.14 [0.83-1.55], P = 0.42; complications, 1.06 [0.97-1,16], P = 1.17; FTR, 1.12 [0.79-1.59], P = 0.52). CONCLUSIONS: Lower income is associated with higher postoperative AEs in the urban setting but not in a rural environment. This socioeconomic disparity in EGS outcomes in urban settings may reflect health care segregation, a differential access to high-quality health care for low-income patients.

No Racial Disparities In Surgical Care Quality Observed After Coronary Artery Bypass Grafting In TRICARE Patients.

In the US, racial disparities in outcomes following coronary artery bypass grafting (CABG) are well documented. TRICARE insurance data represent a large population with universal insurance that allows for the robust assessment of the impact of such insurance on disparities in health care. This study examined racial differences in specific aspects of surgical care quality following CABG, using metrics endorsed by the National Quality Forum that included the prescription of beta-blockers and statins at discharge and thirty-day readmissions. There were no risk-adjusted differences in outcomes between African American and white patients insured through TRICARE. Our study provides a window into the potential impacts of universal insurance and an equal-access health care system on racial disparities in surgical care quality following CABG.

Haemorrhage control in the prehospital setting: a scoping review protocol.

INTRODUCTION: Prehospital haemorrhage control has saved thousands of lives in the military over the last decade. While uncontrolled haemorrhage is a leading cause of preventable injury death in the USA for individuals under 45, military prehospital haemorrhage control techniques have not fully translated to the civilian sector in the USA. The effective implementation of haemorrhage control for civilian prehospital trauma is dependent on a more complex array of system and personnel-level factors than the military. OBJECTIVE: This protocol describes the methodology of a scoping review on haemorrhage control strategies in the prehospital setting; specifically, education, logistics and implementation of these strategies. The aim of the review is to identify research gaps and create recommendations for future research surrounding prehospital layperson haemorrhage control. METHODS: The protocol uses the framework published by The Joanna Briggs Institute and Arksey and O'Malley, while following the Preferred Reporting Items for Systematic Review and Meta-Analysis Extension for Scoping Review Protocols guidelines. The search strategy was refined with the help of a medical librarian. Three peer-reviewed databases (EMBASE, PubMed and Web of Science), databases dedicated to grey literature sources, and reference mining will be used. Two investigators will independently screen and extract data. Discrepancies will be resolved by a third investigator. The extracted data will undergo descriptive analysis of the contextual data and a quantitative analysis using the appropriate statistical methods. In addition, this search strategy will be supplemented by a grey literature search. ETHICS AND DISSEMINATION: Research ethics approval is not required for this scoping review. This scoping review will serve to highlight existing gaps within the literature to guide further research and develop future strategies to improve prehospital haemorrhage management. The results of this review will be presented at relevant national and international conferences and published in a peer-reviewed journal.

Effectiveness of the American College of Surgeons Bleeding Control Basic Training Among Laypeople Applying Different Tourniquet Types: A Randomized Clinical Trial.

Importance: More than 500 000 laypeople in the United States have been trained in hemorrhage control, including tourniquet application, under the Stop the Bleed campaign. However, it is unclear whether after hemorrhage control training participants become proficient in a specific type of tourniquet or can also use other tourniquets effectively. Objective: To assess whether participants completing the American College of Surgeons Bleeding Control Basic (B-Con) training with Combat Application Tourniquets (CATs) can effectively apply bleeding control principles using other tourniquet types (commercial and improvised). Design, Setting, and Participants: This nonblinded, crossover, sequential randomized clinical trial with internal control assessed a volunteer sample of laypeople who attended a B-Con course at Gillette Stadium and the Longwood Medical Area in Boston, Massachusetts, for correct application of each of 5 different tourniquet types immediately after B-Con training from April 4, 2018, to October 9, 2018. The order of application varied for each participant using randomly generated permutated blocks. Interventions: Full B-Con course, including cognitive and skill sessions, that taught bleeding care, wound pressure and packing, and CAT application. Main Outcomes and Measures: Correct tourniquet application (applied pressure of ≥250 mm Hg with a 2-minute time cap) in a simulated scenario for 3 commercial tourniquets (Special Operation Forces Tactical Tourniquet, Stretch-Wrap-and-Tuck Tourniquet, and Rapid Application Tourniquet System) and improvised tourniquet compared with correct CAT application as an internal control using 4 pairwise Bonferroni-corrected comparisons with the McNemar test. Results: A total of 102 participants (50 [49.0%] male; median [interquartile range] age, 37.5 [27.0-53.0] years) were included in the study. Participants correctly applied the CAT at a significantly higher rate (92.2%) than all other commercial tourniquet types (Special Operation Forces Tactical Tourniquet, 68.6%; Stretch-Wrap-and-Tuck Tourniquet, 11.8%; Rapid Application Tourniquet System, 11.8%) and the improvised tourniquet (32.4%) (P < .001 for each pairwise comparison). When comparing tourniquets applied correctly, all tourniquet types had higher estimated blood loss, had longer application time, and applied less pressure than the CAT. Conclusions and Relevance: The B-Con principles for correct CAT application are not fully translatable to other commercial or improvised tourniquet types. This study demonstrates a disconnect between the B-Con course and tourniquet designs available for bystander first aid, potentially stemming from the lack of consensus guidelines. These results suggest that current B-Con trainees may not be prepared to care for bleeding patients as tourniquet design evolves. Trial Registration: ClinicalTrials.gov identifier: NCT03538379.