Impact of the COVID-19 Pandemic on Inpatient and Outpatient Utilization of Bariatric Surgery.

BACKGROUND: During the COVID-19 pandemic, deferral of inpatient elective surgical procedures served as a primary mechanism to increase surge inpatient capacity. Given the benefit of bariatric surgery on treating obesity and associated comorbidities, decreased access to bariatric surgery may have long-term public health consequences. Understanding the extent of the disruption of the COVID-19 pandemic to bariatric surgery will help health systems plan for appropriate access. MATERIALS AND METHODS: This is an observational cohort study using the PINC AI Healthcare Database from 1/1/2019-6/31/2021. A Poisson regression model with patient characteristics and hospital-fixed effects was used to assess the relative monthly within-hospital reduction in surgical encounters, variations by race and ethnicity, and shift from inpatient to outpatient procedures. A multivariate linear probability model was used to assess the change in 30-day readmissions from 2020 and 2021 compared to 2019. RESULTS: Among 309 hospitals, there were 46,539 bariatric procedures conducted in 2019 with a 14.8% reduction in volume to 39,641 procedures in 2020. There were 22,642 bariatric procedures observed from January to June of 2021. The most pronounced decrease in volume occurred in April with an 89.7% relative reduction from 2019. Black and Hispanic patients were more likely to receive bariatric surgery after the height of the pandemic compared to white patients. A clinically significant shift from inpatient to outpatient bariatric surgical procedures was not observed. Relative to 2019, there were no significant differences in bariatric surgical readmission rates. CONCLUSION: During the pandemic there was a sizable decrease in bariatric surgical volume. There did not appear to be disparities in access to bariatric surgery for minority patients. We did not observe a meaningful shift toward outpatient bariatric surgical procedures. Post-pandemic, monitoring is needed to assess if hospitals have been able to meet the demand for bariatric surgical procedures.

Reduction in Prescribed Opioids after General Surgery Procedures at a Public Hospital.

Overdose of opioids is the number one cause of accidental death in the United States, and surgeons are overprescribing these medications. The aim of this study was to assess the feasibility of implementing postoperative opioid prescribing guidelines for general surgery procedures at a public hospital, where patients have lower socioeconomic status, public insurance, and limited access to care. We implemented a quality improvement project, which included in-service training for surgical staff and distribution of standardized guidelines. An infographic for patients was created to facilitate education on postoperative pain management. Pre- and postintervention opioid prescriptions and emergency room visits were compared for patients undergoing common general surgery procedures (inguinal hernia repair, appendectomy, and laparoscopic cholecystectomy). The median number of narcotic pills prescribed significantly decreased from 30 (n = 64) to 15 (n = 63) after the intervention (P < 0.0001). Morphine milligram equivalents decreased from a median [range] of 150 [20,600] to 90 [5,300] (P < 0.0001). The percentage of patients with postoperative pain-related emergency department visits remained low (1.6%). Standardization of postoperative opioid prescription practices was successfully implemented at a public hospital without an increase in the number of emergency room visits for pain.

Investigating Gender Differences in Faculty Evaluations by Trainees in a Gender-Balanced General Surgery Program.

PURPOSE: Women account for 21% of faculty positions in general surgery. In fields with lower female representation, female faculty receive lower evaluation scores by trainees compared to male faculty. At 42%, the female faculty representation in our general surgery department doubles the national average. We sought to determine if variations in faculty evaluations would be observed in a more gender-balanced general surgery program. METHODS: Two years of faculty teaching evaluations by residents in a general surgery residency program were collected from the MedHub system. Total 3277 resident evaluations of 26 faculty members (11 female, 15 male) were analyzed. Seven areas (scored 1-7, with 1 = needs improvement and 7 = outstanding) were examined. Chi-square test was used to compare the percentage of male and female faculty members who scored a 6 or 7 in each category, and multivariate logistic regression analysis was used to determine the association of gender with the evaluation score, while adjusting for the number of encounters between the trainee and the faculty member. RESULTS: There were no significant differences between male and female faculty in the "overall" evaluation score, nor in the "practice-based learning" and the "interpersonal and communication skills" categories. Female faculty had statistically significantly higher scores in "patient care", "professionalism," and "systems-based care" categories, whereas male faculty had higher evaluations in the "medical knowledge" category. CONCLUSION: In a general surgery residency program with a relatively gender-balanced faculty, there was no gender difference in the "overall" evaluation of faculty by residents. However, there were gender differences in specific domains. These findings suggest that gender balance in teaching faculty may help eliminate previously observed teaching evaluation bias in the traditionally male dominated fields.

Follow-up trends after emergency department discharge for acutely symptomatic hernias: A southwestern surgical congress multi-center trial.

BACKGROUND: The objective of this multi-center study was to examine the follow-up trends after emergency department (ED) discharge in a large and socioeconomically diverse patient population. METHODS: We performed a 3-year retrospective analysis of adult patients with acutely symptomatic hernias who were discharged from the EDs of five geographically diverse hospitals. RESULTS: Of 674 patients, 288 (43%) were evaluated in the clinic after discharge from the ED and 253 (37%) underwent repair. Follow-up was highest among those with insurance. A total of 119 patients (18%) returned to the ED for hernia-related complaints, of which 25 (21%) underwent urgent intervention. CONCLUSION: The plan of care for patients with acutely symptomatic hernias discharged from the ED depends on outpatient follow-up, but more than 50% of patients are lost to follow-up, and nearly 1 in 5 return to the ED. The uninsured are at particularly high risk.

Energy cost of walking, symptomatic fatigue and perceived exertion in persons with multiple sclerosis.

A higher energy cost of walking (Cw) is sometimes observed in MS, and could contribute to fatigue. The purpose of this study was to compare Cw at three speeds in MS and controls, and determine the effects of walking speed on fatigue and perceived exertion. We hypothesized that MS would have higher Cw, fatigue and exertion during walking than controls. Ten persons with MS and 14 controls of similar age and physical activity levels were studied. Oxygen consumption (VO2) was obtained at rest and during treadmill walking at 0.6 and 1.4ms(-1), and preferred speed. Cw was calculated as net VO2:velocity. Fatigue and exertion were assessed using the visual analog fatigue and modified Borg scales, respectively. Preferred treadmill speed was not different between groups. Cw was higher in MS than controls across walking speeds (p=0.003), with a group-by-speed interaction indicating higher Cw in MS at 0.6ms(-1) (p=0.001), but not at preferred speed or 1.4ms(-1). MS reported greater fatigue (p=0.001) and exertion (p=0.004) at all speeds. Despite similar preferred speeds, and Cw at preferred and fast speeds, MS exhibited higher fatigue and exertion at all walking speeds. These results suggest that increased energy demands in MS are most notable at low speeds such as those used in everyday activities, which may contribute to fatigue over the day.

Pyloroplasty for Refractory Gastroparesis.

Gastroparesis is a chronic gastric motility disorder in which the pathophysiology mimics a postvagotomy state. Pyloroplasty is beginning to emerge as a successful drainage procedure for refractory gastroparesis. Here we report our experience using pyloroplasty in the surgical management of diabetic and nondiabetic gastroparesis. A retrospective study was performed of 46 patients undergoing pyloroplasty for refractory gastroparesis from January 2010 through December 2013. Gastric emptying scintigraphy and the Gastroparesis Cardinal Symptom Index were assessed pre- and postoperatively. Laparoscopic pyloroplasty was performed in 42 patients, open pyloroplasty in three, and one patient was converted from laparoscopic to open pyloroplasty. Studies were repeated during the six to 12 month postoperative interval. The postoperative gastric emptying scintigraphy improved in 90 per cent of patients and normalized in 60 per cent. Postoperative T½ was significantly reduced (P = 0.001) as was four-hour retention (P < 0.001). The Gastroparesis Cardinal Symptom Index showed statistically significant reduction in symptom severity for all nine categories (P < 0.0005) as well as total symptom score (P < 0.005). No patients developed dumping syndrome. Pyloroplasty is a highly effective therapy for refractory gastroparesis, offering significant reduction in symptom severity, improvement in quality of life, and acceleration of gastric emptying.