Christopher P. Scally

Early impact of the 2011 ACGME duty hour regulations on surgical outcomes

BACKGROUND In 2011, the Accreditation Council for Graduate Medical Education (ACGME) implemented additional restrictions on resident work hours. Although the impact of these restrictions on the education of surgical trainees has been examined, the effect on patient safety remains poorly understood. METHODS We used national Medicare Claims data for patients undergoing general (n = 1,223,815) and vascular (n = 475,262) surgery procedures in the 3 years preceding the duty hour changes (January, 2009-June, 2011) and the 18 months thereafter (July, 2011-December, 2012). Hospitals were stratified into quintiles by teaching intensity using a resident to bed ratio. We utilized a difference-in-differences analytic technique, using nonteaching hospitals as a control group, to compare risk-adjusted 30-day mortality, serious morbidity, readmission, and failure to rescue (FTR) rates before and after the duty hour changes. RESULTS After duty hour reform, no changes were seen in the measured outcomes when comparing teaching with nonteaching hospitals. Even when stratifying by teaching intensity, there were no differences. For example, at the highest intensity teaching hospitals (resident/bed ratio of ≥ 0.6), mortality rates before and after the duty hour changes were 4.2% and 4.0%, compared with 4.7% and 4.4% for nonteaching hospitals (relative risk [RR], 0.98; 95% CI, 0.89-1.07). Similarly, serious complication (RR, 1.02; 95% CI, 0.98-1.06), FTR (RR, 0.95; 95% CI, 0.87-1.04), and readmission (odds ratio, 1.00; 95% CI, 0.96-1.03) rates were unchanged. CONCLUSION In Medicare beneficiaries undergoing surgery at teaching hospitals, outcomes have not improved since the 2011 ACGME duty hour regulations.

Progressive Entrustment to Achieve Resident Autonomy in the Operating Room: A National Qualitative Study With General Surgery Faculty and Residents.

Objective: The purpose of this study was to identify behaviors that faculty and residents exhibit during intraoperative interactions, which support or inhibit progressive entrustment leading to operative autonomy. Background: In the operating room, a critical balance is sought between direct faculty supervision and appropriate increase in resident autonomy with indirect faculty supervision. Little is known regarding perspectives of faculty and residents about how attendings increasingly step back and safely delegate autonomy to trainees. Understanding the context in which these decisions are made is critical to achieving a safe strategy for imparting progressive responsibility. Methods: A qualitative study was undertaken from January 2014 to February 2015. Semistructured interviews were conducted with 37 faculty and 59 residents from 14 and 41 institutions, respectively. Participants were selected using stratified random sampling from general surgery residency programs across the United States to represent a range of university, university-affiliated, and community programs, and geographic regions. Audio recordings of interviews were transcribed, iteratively analyzed, and emergent themes identified. Results: Six themes were identified as influencing progressive entrustment in the operating room: optimizing faculty intraoperative feedback; policies and regulations affecting role of resident in the operating room; flexible faculty teaching strategies; context-specific variables; leadership opportunities for resident in the case; and safe struggle for resident when appropriate. Conclusions: Perspectives of faculty and residents while overlapping were different in emphasis. Better understanding faculty–resident interactions, individual behaviors, contextual influences, and national regulations that influence intraoperative education have the potential to significantly affect progressive entrustment in training paradigms.

Preserving operative volume in the setting of the 2011 ACGME duty hour regulations

OBJECTIVES The reported influence of Accreditation Council for Graduate Medical Education resident duty hour limitations on operative case volume has been mixed. Additional restrictions instituted in July 2011 further limited the work hours of postgraduate year 1 (PGY-1) residents, threatening to reduce availability for educational and operative activities. In this study, we evaluate our novel intern call schedule, which we hypothesized would preserve operative experience despite these increased restrictions. DESIGN A retrospective analysis of PGY-1 operative reports was conducted. Operations outside of major case categories were excluded. Operative case volumes in the Section of General Surgery for the same period were analyzed, as were average duty hours for each resident. Comparative statistics were generated using Wilcoxon rank sum tests. SETTING Single-institution study conducted at the University of Michigan, a tertiary-care academic hospital. PARTICIPANTS Overall, 50 categorical general surgery residents from 2005 to present were included. Three residents were subsequently excluded as they were preliminary interns rather than categorical; 2 residents were excluded having completed their intern years at other institutions. RESULTS The median number of major cases done during the PGY-1 for all evaluated residents was 89 (interquartile range [IQR]: 72-101). For interns between the years 2005 and 2011, the median number of major cases was 87 (IQR: 73-101), whereas interns in the 2011 to 2013 academic years performed 91.5 (IQR: 69.5-101.5, p = 0.91). Although case volume varied between intern classes, no significant differences were observed between any 2 individual classes in the study. Analysis of annual case volumes among each PGY revealed a relative increase of 29% (p < 0.001) among PGY-2 residents, and 20% (p = 0.02) by PGY-3 residents. Relative increases among senior residents (8% for both PGY-4 and PGY-5) did not reach statistical significance. CONCLUSIONS Our novel call schedule attempts to minimize prolonged night-float coverage responsibilities for interns in hopes of preserving their operative experience. In spite of increased duty hour restrictions, PGY-1 operative volume has not decreased significantly at our institution. However, in the same time period, PGY-2 and PGY-3 case volume has increased. Our findings highlight the challenges faced by surgical residencies in light of these new restrictions, particularly the 16-hour limit. Additional rigorously designed prospective studies should be conducted to better understand the influence of the most recent Accreditation Council for Graduate Medical Education work hour limitations on the subjective and objective experiences of surgical residents.

Intensity of follow-up after melanoma surgery.

This contemporary review of melanoma surveillance strategies seeks to help practitioners examine and improve their surveillance protocols based on the currently available data. In general, there is no definitive benefit from increased screening or more aggressive use of interval imaging. Low-intensity surveillance strategies do not appear to adversely affect patient outcomes and should be the preferred approach compared with high-intensity strategies for most melanoma patients. All surveillance programs should emphasize education in order to maximize the effectiveness of patient-based detection of recurrent disease.

Evaluation of the Effectiveness of a Surgical Checklist in Medicare Patients.

Background:Surgical checklists are increasingly used to improve compliance with evidence-based processes in the perioperative period. Although enthusiasm exists for using checklists to improve outcomes, recent studies have questioned their effectiveness in large populations. Objective:We sought to examine the association of Keystone Surgery, a statewide implementation of an evidence-based checklist and Comprehensive Unit–based Safety Program, on surgical outcomes and health care costs. Methods:We performed a study using national Medicare claims data for patients undergoing general and vascular surgery (n=1,002,241) from 2006 to 2011. A difference-in-differences approach was used to evaluate whether implementation was associated with improved surgical outcomes and decreased costs when compared with a national cohort of nonparticipating hospitals. Propensity score matching was used to select 10 control hospitals for each participating hospital. Costs were assessed using price-standardized 30-day Medicare payments for acute hospitalizations, readmissions, and high-cost outliers. Results:Keystone Surgery implementation in participating centers (N=95 hospitals) was not associated with improved outcomes. Difference-in-differences analysis accounting for trends in nonparticipating hospitals (N=950 hospitals) revealed no differences in adjusted rates of 30-day mortality [relative risk (RR)=1.03; 95% confidence intervals (CI), 0.97–1.10], any complication (RR=1.03; 95% CI, 0.99–1.07), reoperations (RR=0.89; 95% CI, 0.56–1.22), or readmissions (RR=1.01; 95% CI, 0.97–1.05). Medicare payments for the index admission increased following implementation (

Comparing perioperative processes of care in high and low mortality centers performing pancreatic surgery.

516 average increase in payments; 95% CI,

Hospital Teaching Status and Medicare Expenditures for Complex Surgery: Retrospective Cohort Study.

210–

Medical School Training for the Surgeon

823 increase), as did readmission payments (

National trends in resection of cystic lesions of the pancreas

564 increase; 95% CI,

Impact of Surgical Quality Improvement on Payments in Medicare Patients.

89–