Caprice C. Greenberg

Postgame analysis: Using video-based coaching for continuous professional development

BACKGROUND The surgical learning curve persists for years after training, yet existing continuing medical education activities targeting this are limited. We describe a pilot study of a scalable video-based intervention, providing individualized feedback on intraoperative performance. STUDY DESIGN Four complex operations performed by surgeons of varying experience--a chief resident accompanied by the operating senior surgeon, a surgeon with less than 10 years in practice, another with 20 to 30 years in practice, and a surgeon with more than 30 years of experience--were video recorded. Video playback formed the basis of 1-hour coaching sessions with a peer-judged surgical expert. These sessions were audio recorded, transcribed, and thematically coded. RESULTS The sessions focused on operative technique--both technical aspects and decision-making. With increasing seniority, more discussion was devoted to the optimization of teaching and facilitation of the residents technical performance. Coaching sessions with senior surgeons were peer-to-peer interactions, with each discussing his preferred approach. The coach alternated between directing the session (asking probing questions) and responding to specific questions brought by the surgeons, depending on learning style. At all experience levels, video review proved valuable in identifying episodes of failure to progress and troubleshooting alternative approaches. All agreed this tool is a powerful one. Inclusion of trainees seems most appropriate when coaching senior surgeons; it may restrict the dialogue of more junior attendings. CONCLUSIONS Video-based coaching is an educational modality that targets intraoperative judgment, technique, and teaching. Surgeons of all levels found it highly instructive. This may provide a practical, much needed approach for continuous professional development.

Toolbox to Reduce Lumpectomy Reoperations and Improve Cosmetic Outcome in Breast Cancer Patients: The American Society of Breast Surgeons Consensus Conference

BackgroundMultiple recent reports have documented significant variability of reoperation rates after initial lumpectomy for breast cancer. To address this issue, a multidisciplinary consensus conference was convened during the American Society of Breast Surgeons 2015 annual meeting.MethodsThe conference mission statement was to “reduce the national reoperation rate in patients undergoing breast conserving surgery for cancer, without increasing mastectomy rates or adversely affecting cosmetic outcome, thereby improving value of care.” The goal was to develop a toolbox of recommendations to reduce the variability of reoperation rates and improve cosmetic outcomes. Conference participants included providers from multiple disciplines involved with breast cancer care, as well as a patient representative. Updated systematic reviews of the literature and invited presentations were sent to participants in advance. After topic presentations, voting occurred for choice of tools, level of evidence, and strength of recommendation.ResultsThe following tools were recommended with varied levels of evidence and strength of recommendation: compliance with the SSO-ASTRO Margin Guideline; needle biopsy for diagnosis before surgical excision of breast cancer; full-field digital diagnostic mammography with ultrasound as needed; use of oncoplastic techniques; image-guided lesion localization; specimen imaging for nonpalpable cancers; use of specialized techniques for intraoperative management, including excisional cavity shave biopsies and intraoperative pathology assessment; formal pre- and postoperative planning strategies; and patient-reported outcome measurement.ConclusionsA practical approach to performance improvement was used by the American Society of Breast Surgeons to create a toolbox of options to reduce lumpectomy reoperations and improve cosmetic outcomes.

Optimizing Cancer Care Delivery through Implementation Science.

The 2013 Institute of Medicine report investigating cancer care concluded that the cancer care delivery system is in crisis due to an increased demand for care, increasing complexity of treatment, decreasing work force, and rising costs. Engaging patients and incorporating evidence-based care into routine clinical practice are essential components of a high-quality cancer delivery system. However, a gap currently exists between the identification of beneficial research findings and the application in clinical practice. Implementation research strives to address this gap. In this review, we discuss key components of high-quality implementation research. We then apply these concepts to a current cancer care delivery challenge in women’s health, specifically the implementation of a surgery decision aid for women newly diagnosed with breast cancer.

Preoperative factors predict mortality after major lower-extremity amputation

BACKGROUND The objective was to develop a preoperative mortality risk stratification tool for patients facing major amputation. METHODS Patients who underwent above-knee (AKA) or below-knee amputation (BKA) from 2005 to 2010 were identified from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database. Univariate and multivariate analyses were performed to determine the association of preoperative factors with 30-day mortality. Multivariable models were used to create a computerized prediction tool. RESULTS Of 9,368 patients, 4,032 underwent AKA and 5,336 BKA. The 30-day mortality rate after AKA was 12.8%, almost double that of BKA (6.5%, P < .001). The complication rate was statistically greater after AKA although numerically similar (28.5% vs 26.6%, P = .020), whereas the rate of reoperation was substantially greater after BKA (22.7% vs 11.7%, P < .001). Preoperative factors that predicted mortality after both procedures included older age, dependent functional status, dialysis, steroid use, preoperative sepsis, delirium, thrombocytopenia, increased international normalized ratio, and azotemia. Prediction tools were developed and validated, and their concordance indices were 0.75 for AKA and 0.81 for BKA, indicating good predictive accuracy. CONCLUSION Preoperative factors predict mortality after major amputation, and the risk calculator that we have developed may facilitate informed decision-making and provide realistic expectations for surgeons and patients faced with limb-threatening disease.

Impact of neoadjuvant chemotherapy on wound complications after breast surgery.

BACKGROUND Use of neoadjuvant chemotherapy for breast cancer is increasing. The objective was to examine risk of postoperative wound complications in patients receiving neoadjuvant chemotherapy for breast cancer. METHODS Patients undergoing breast surgery from 2005 to 2010 were selected from the American College of Surgeons National Surgical Quality Improvement Program database. Patients were included if preoperative diagnosis suggested malignancy and an axillary procedure was performed. We performed a stepwise multivariable regression analysis of predictors of postoperative wound complications, overall and stratified by type of breast surgery. Our primary variable of interest was receipt of neoadjuvant chemotherapy. RESULTS Of 44,533 patients, 4.5% received neoadjuvant chemotherapy. Wound complications were infrequent with or without neoadjuvant chemotherapy (3.4% vs. 3.1%; P = .4). Smoking, functional dependence, obesity, diabetes, hypertension, and mastectomy were associated with wound complications. No association with neoadjuvant chemotherapy was seen (odds ratio [OR], 1.01; 95% confidence interval [CI], 0.78-1.32); however, a trend was observed toward increased complications in neoadjuvant patients undergoing mastectomy with immediate reconstruction (OR, 1.58; 95% CI, 0.98-2.58). CONCLUSION Postoperative wound complications after breast surgery are infrequent and not associated with neoadjuvant chemotherapy. Given the trend toward increased complications in patients undergoing mastectomy with immediate reconstruction, however, neoadjuvant chemotherapy should be among the many factors considered when making multidisciplinary treatment decisions.

Contralateral Prophylactic Mastectomy (CPM) Consensus Statement from the American Society of Breast Surgeons: Data on CPM Outcomes and Risks.

The American Society of Breast Surgeons (ASBrS) endorses the American Board of Internal Medicine’s Choosing Wisely campaign statement: “Don’t routinely perform a double mastectomy in patients who have a single breast with cancer.”1 However, women with a newly diagnosed unilateral breast cancer are increasingly opting for bilateral mastectomy. This has been seen in patients who are candidates for breast conservation who elect mastectomy as well as those requiring mastectomy for their index breast cancer.2 National rates of contralateral prophylactic mastectomy (CPM) in the United States have been increasing and this trend is continuing.2–4

Deconstructing intraoperative communication failures.

BACKGROUND Communication failure is a common contributor to adverse events. We sought to characterize communication failures during complex operations. METHODS We video recorded and transcribed six complex operations, representing 22 h of patient care. For each communication event, we determined the participants and the content discussed. Failures were classified into four types: audience (key individuals missing), purpose (issue nonresolution), content (insufficient/inaccurate information), and/or occasion (futile timing). We added a systems category to reflect communication occurring at the organizational level. The impact of each identified failure was described. RESULTS We observed communication failures in every case (mean 29, median 28, range 13-48), at a rate of one every 8 min. Cross-disciplinary exchanges resulted in failure nearly twice as often as intradisciplinary ones. Discussions about or mandated by hospital policy (20%), personnel (18%), or other patient care (17%) were most error prone. Audience and purpose each accounted for >40% of failures. A substantial proportion (26%) reflected flawed systems for communication, particularly those for disseminating policy (29% of system failures), coordinating personnel (27%), and conveying the procedure planned (27%) or the equipment needed (24%). In 81% of failures, inefficiency (extraneous discussion and/or work) resulted. Resource waste (19%) and work-arounds (13%) also were frequently seen. CONCLUSIONS During complex operations, communication failures occur frequently and lead to inefficiency. Prevention may be achieved by improving synchronous, cross-disciplinary communication. The rate of failure during discussions about/mandated by policy highlights the need for carefully designed standardized interventions. System-level support for asynchronous perioperative communication may streamline operating room coordination and preparation efforts.

Rehospitalization to Primary Versus Different Facilities Following Abdominal Aortic Aneurysm Repair

OBJECTIVE Reducing readmissions represents a unique opportunity to improve care and reduce health care costs and is the focus of major payers. A large number of surgical patients are readmitted to hospitals other than where the primary surgery was performed, resulting in clinical decisions that do not incorporate the primary surgeon and potentially alter outcomes. This study characterizes readmission to primary vs different hospitals after abdominal aortic aneurysm (AAA) repair and examines the implications with regard to mortality and cost. METHODS Patients who underwent open or endovascular aneurysm repair for AAA were identified from the Centers for Medicare and Medicaid Services Chronic Conditions Warehouse, a random 5% national sample of Medicare beneficiaries from 2005 to 2009. Outcomes for patients who underwent AAA repair and were readmitted within 30 days of initial discharge were compared based on readmission location (primary vs different hospital). RESULTS A total of 885 patients underwent AAA repair and were readmitted within 30 days. Of these, 626 (70.7%) returned to the primary facility, and 259 (29.3%) returned to a different facility. Greater distance from patient residence to the primary hospital was the strongest predictor of readmission to a different facility. Patients living 50 to 100 miles from the primary hospital were more likely to be readmitted to a different hospital compared with patients living <10 miles away (odds ratio, 8.50; P < .001). Patients with diagnoses directly related to the surgery (eg, wound infection) were more likely to be readmitted to the primary hospital, whereas medical diagnoses (eg, pneumonia and congestive heart failure) were more likely to be treated at a different hospital. There was no statistically significant difference in mortality between patients readmitted to a different or the primary hospital. Median total 30-day payments were significantly lower at different vs primary hospitals (primary,

Quantifying technical skills during open operations using video-based motion analysis

11,978 vs different,

The General Surgery Job Market: Analysis of Current Demand for General Surgeons and Their Specialized Skills

11,168; P = .04). CONCLUSIONS Readmission to a different facility after AAA repair is common and occurs more frequently than for the overall Medicare population. Patients travelling a greater distance for AAA repair are more likely to return to different vs the primary hospital when further care is required. For AAA repair, quality healthcare may be achieved at marginally lower cost and with greater patient convenience for selected readmissions at hospitals other than where the initial procedure was performed.