Cultural Complications Curriculum: Applicability to Surgical Oncology Programs and Practices.

BACKGROUND: Recognizing the need to raise awareness of core diversity, equity, and inclusion (DEI) issues in the healthcare system, our previously developed Cultural Complications Curriculum aims to support institutions in reducing cultural error. As we continue program deployment, we discuss the opportunity to apply the Cultural Complications Curriculum to multidisciplinary audiences, such as in cancer programs. METHODS: We discuss applicability of the Cultural Complications Curriculum to cancer programs and practices, including how to tailor case discussions to oncology audiences. By emphasizing the unique characteristics of the multidisciplinary care environment and anticipating potential barriers to curriculum implementation, we demonstrate how the Cultural Complications Curriculum may support culture improvement across broad audiences. RESULTS: The successful application of the Cultural Complication Curriculum to multidisciplinary care programs will depend on appreciating differences in background knowledge, tailoring discussions to audience needs, and adapting material by incorporating new data and addressing emerging DEI issues. Multidisciplinary environments may require innovative approaches to education including virtual platforms, increased collaboration across centers and systems, and support from professional societies. In integrated care environments, like oncology, effective DEI discussions call for the engagement of a variety of medical specialties and departments. CONCLUSIONS: To meet the needs of an increasingly diverse patient population and workforce, our approach to DEI education must embrace the interdependent nature of care delivery. In oncology and other multidisciplinary care environments, application of the Cultural Complications Curriculum may be the first step to combating cultural error by engaging a broader demographic within our healthcare system.

Not Further Specified: Unclassified Orthopedic Injuries in Trauma Registries, Cause for Concern?

BACKGROUND: Data accuracy is essential to obtaining correct results and making appropriate conclusions in outcomes research. Few have examined the quality of data that is used in studies involving orthopedic surgery. A nonspecific data entry has the potential to affect the results of a study or the ability to appropriately risk adjust for treatments and outcomes. This study evaluated the proportion of Not Further Specified (NFS) orthopedic injury codes found into two large trauma registries. MATERIALS: Data from the National Trauma Data Bank (NTDB) from 2011 to 2015 and from the Michigan Trauma Quality Improvement Program (MTQIP) 2011-2017 were used. We selected multiple orthopedic injuries classified via the Abbreviated Injury Scale, version 2005 (AIS2005) and calculated the percentage of NFS entries for each specific injury. RESULTS: There were a substantial proportion of fractures classified as NFS in each registry, 18.5% (range 2.4%-67.9%) in MTQIP and 27% (range 6.0%-68.5%) in the NTDB. There were significantly more NFS entries when the fractures were complex versus simple in both MTQIP (34.5% versus 9.6%, P < 0.001) and the NTDB (41.8% versus 15.7%, P < 0.001). The level of trauma center affected the proportion of NFS codes differently between the registries. CONCLUSIONS: The proportion of nonspecific entries in these two large trauma registries is concerning. These data can affect the results and conclusions from research studies as well as impact our ability to truly risk adjust for treatments and outcomes. Further studies should explore the reasons for these findings.

Impact of Cumulative Corticosteroid Dosage on Preventable Hospitalization among Taiwanese Patients with Ankylosing Spondylitis and Inflammatory Bowel Disease.

Background: Corticosteroids are commonly prescribed for autoimmune conditions, but their impact on preventable hospitalization rates is unclear. This study sought to investigate the effect of corticosteroid use on hospitalization for ambulatory care sensitive conditions among Taiwanese patients with ankylosing spondylitis (AS) or inflammatory bowel disease (IBD). Methods: This was a retrospective cohort study using adults in the Taiwan National Health Insurance Research database receiving a new diagnosis of AS (n = 40,747) or IBD (n = 4290) between January 2002 and June 2013. Our main outcome measure was odds of preventable hospitalization for eight ambulatory care-sensitive conditions defined by the Agency for Healthcare Research and Quality. Results: In the first quarter (three months) following diagnosis, corticosteroid usage was common among patients with AS and IBD (18.5% and 30%, respectively). For every 100 mg increase in corticosteroid dose per quarter, adjusted odds of preventable hospitalization in the following quarter increased by 5.5% for patients with AS (aOR = 1.055, 95% CI 1.037-1.074) and 6.4% for those with IBD (aOR = 1.064, 95% CI 1.046-1.082). Conclusions: Relatively low doses of corticosteroids significantly increase AS and IBD patients' short-term odds of hospitalization for ambulatory care-sensitive conditions. As recommended by current clinical guidelines, physicians should use corticosteroids sparingly in these populations, and prioritize initiation/escalation of disease-modifying anti-rheumatic drugs for long-term management. If corticosteroids cannot be avoided, patients may require monitoring and/or prophylaxis for corticosteroid-associated comorbidities (e.g., diabetes) which can result in preventable hospitalizations.

Editorial (Spring) Board? Gender Composition in High-impact General Surgery Journals Over 20 Years.

OBJECTIVE: To quantify gender composition of 10 high-impact general surgery journals, delineate how board composition has changed over time, and evaluate qualification metrics by gender. BACKGROUND: Underrepresentation of women on editorial boards may contribute to the gender-based achievement gap in surgery. METHODS: We performed a cross-sectional analysis of the editorial board gender composition among 10 high-impact general surgery journals in 1997, 2007, and 2017. Univariate and multivariate regression analyses were used to assess differences in editors' H-indices, academic rank, and number of advanced degrees. Differences in editor turnover and multiple board positions were evaluated for each time interval. RESULTS: Over 20 years, the proportion of women on editorial boards increased from 5% to 19%. After controlling for time since board certification, no differences between men and women's number of advanced degrees, H-indices, or academic rank remained significant. Women and men were equally likely to hold multiple board positions (1997 P = 0.74; 2007 P = 0.42; 2017 P = 0.69), but men's editorial board tenure was longer across each time interval (1997-2007 P = 0.003; 2007-2017 P < 0.001; 1997-2017 P = 0.01). CONCLUSIONS: Women surgeons have a small but growing presence on surgical editorial boards, and gender-based qualification differences are likely attributable to practice length. Men's longer tenure on editorial boards may drive some of the observed disparity by limiting new appointment opportunities. Strategies such as imposing term limits or instituting merit-based performance reviews may help editorial boards capture the field's changing demographics.

The golden year: How functional recovery sets the stage for tendon transfer surgery among patients with tetraplegia-a qualitative analysis.

BACKGROUND: Tendon transfer surgery can effectively improve hand function for patients with tetraplegia but remains poorly utilized. Little is known regarding how patients' rehabilitation experiences influence their perception of function, identity, and coping to shape their reconstructive context. METHODS: We performed a cross-sectional qualitative analysis of 19 participants with C4-C7 cervical spinal injuries: 9 patients had undergone reconstruction; 10 had not. Semistructured interviews were conducted using an interview guide focusing on rehabilitation experience, the relationship between function and identity, and how patient experience evolved. Interview transcripts were analyzed using grounded theory. RESULTS: The study sample was predominantly male (79%), white (89%), and American Spinal Injury Association grades A-D (grade A: 42%; grade B: 32%; grade C: 16%; grade D: 10%). Recognizing rehabilitation's necessity, functional gains, and constructive patient-therapist relationships promoted engagement in therapy. Poor insurance coverage and financial constraints decreased rehabilitation access. Function affected identity through the degree to which it tied participants to a "patient" role. Early in recovery, patients' function, roles, and attitudes were fluid but solidified over time; how satisfied patients were with these final positions influenced how they coped. CONCLUSION: The balance of patients' positive and negative coping has been found to influence patients' progression to surgery. This study describes how function and identity contribute to coping. Participants' function and identity evolved during a finite period we call "the golden year," before reaching a fixed point around which they built their lives. The norms patients establish during this time may affect receptiveness to surgery.

Understanding Patient Preferences in Proximal Interphalangeal Joint Surgery for Osteoarthritis: A Conjoint Analysis.

PURPOSE: We sought to compare preferences for arthroplasty versus arthrodesis among patients with proximal interphalangeal (PIP) joint osteoarthritis (OA) by quantifying the patient-assigned utility of each operation's attributes. METHODS: We undertook a multistep process to identify relevant surgical attributes, including a literature review, surgeon survey, and pretest patient pilot test to build a set of discrete choice experiments. Patients with PIP joint osteoarthritis were identified using a single university electronic medical record and were recruited via electronic message or postcard. Participants completed a demographic survey and 11 discrete choice experiments designed using Sawtooth Software's Discover tool. Utility and importance scores were generated for each attribute. RESULTS: Pretest analysis identified out-of-pocket cost, joint stiffness, need for future surgery, change in grip strength, and total recovery time as the most important surgical attributes. Initial response rate to the conjoint survey was 75% and survey completion rate was 61%. The study sample was predominantly white (91%) and female (72%), mean age 64.3 years (range, 34-90 years), and mean daily pain score was 4.32 (range, 0-10). Attribute importance scores demonstrated that joint stiffness (32%) and grip strength (29%) were most important to patients. Cost (17%) and need for future surgery (19%) were intermediate patient-preference drivers. Recovery time was the least important attribute (2%). CONCLUSIONS: In aggregate, patients prefer surgical attributes characteristic of arthroplasty (ability to preserve joint motion and grip strength) relative to those associated with arthrodesis (decreased need for reoperation, lower costs, and shorter reoperation times). TYPE OF STUDY/LEVEL OF EVIDENCE: Economic/Decision Analysis III.

Leveraging the Medical Context to Increase Upper Extremity Reconstruction Among Patients With Tetraplegia: A Qualitative Analysis.

OBJECTIVES: To (1) characterize patients' medical experiences from initial injury until they become candidates for upper extremity reconstruction (UER); and (2) identify points in this medical context that may be most amenable to interventions designed to increase UER utilization. DESIGN: A qualitative cross-sectional study using grounded theory methodology and constant comparative analysis of data collected through semistructured individual interviews. SETTING: Community. PARTICIPANTS: A sample of individuals with C4 to C8 cervical spinal injuries (N=19) who sustained injuries at least 1 year before interview. Nine patients had undergone reconstruction, and 10 had not. The study sample was predominantly male (79%) and white (89%), and American Spinal Injury Association grades A through D were represented (A, 42%; B, 32%; C, 16%; D, 10%). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Participants' self-report of their medical experiences from the time of injury through the early recovery period. RESULTS: We identified 3 domains that formed patients' medical context before UER candidacy: (1) their ability to achieve and maintain health; (2) their relationship with health care providers; and (3) their expectations regarding clinicians' tetraplegia-specific expertise. Trust emerged as a major theme driving potential intervention targets. Patients transferred to referral centers had higher trust in tertiary providers relative to local physicians. In the outpatient setting, patients' trust correlated with the tetraplegia-specific expertise level they perceived the specialty to have (high for physical medicine and rehabilitation, intermediate for urology, low for primary care). CONCLUSIONS: In appropriate candidates, UER produces substantial functional gains, but reconstruction remains underused in the tetraplegic population. By analyzing how patients achieve health and build trust in early recovery/injury, our study provides strategies to improve UER access. We propose that interventions targeting highly trusted points of care (transfer hospitals) and avoiding low-trust points (primary care physicians, home health) will be most effective. Urology may represent a novel entry point for UER interventions.

What is in a Pronoun?: Why Gender-fair Language Matters.

MINI: Mounting evidence demonstrates that gender inequity is perpetuated by language. As such, understanding the ways in which linguistic bias reinforces gender and other stereotypes is paramount to creating a culture of inclusivity. This perspective reviews the science detailing the ways language reinforces gender inequality and offers strategies to reduce linguistic bias.

Checkpoints to Progression: Qualitative Analysis of the Personal and Contextual Factors That Influence Selection of Upper Extremity Reconstruction Among Patients With Tetraplegia.

PURPOSE: Patients with tetraplegia consistently rank better use of the upper extremity as their top functional priority. Multiple case series have demonstrated that upper extremity reconstruction (UER) is well-tolerated and can produce substantial functional improvements for appropriate candidates; however, UER remains critically underutilized. The mechanisms that drive differences in provider practice and referral patterns have been studied, but comprehensive examination of the patient factors that influence UER decisions has not been performed for American patients. METHODS: Nineteen patients with C4-8 cervical spinal injuries were selected using purposive sampling: 9 patients had undergone UER, 10 had not undergone UER. Semistructured interviews were conducted and transcripts evaluated using grounded theory methodology. RESULTS: Our study yielded a conceptual model that describes the characteristics common to all patients who undergo UER. Patients who selected reconstruction proceeded stepwise through a shared sequence of steps: (1) functional dissatisfaction, (2) awareness of UER, and (3) acceptance of surgery. Patients' ability to meet these criteria was determined by 3 checkpoints: how well they coped, their access to information, and the acceptability of surgery. Extremely positive or negative coping prevented patients from moving from the Coping to the Information Checkpoint; thus, they remained unaware of UER and did not undergo surgery. A lack of knowledge regarding reconstruction was the strongest barrier to surgery among our participants. CONCLUSIONS: We built a conceptual model that outlines how patients' personal and contextual factors drive their progression to UER. Moving from functional dissatisfaction to understanding that they were candidates for UER was a substantial barrier for participants, particularly those with very high and very low coping skills. CLINICAL RELEVANCE: To improve utilization for all patients, interventions are needed to increase UER awareness. Standardizing introduction to UER during the rehabilitation process or improving e-content may represent key awareness access points.