Kristen A. Ban

Epidemiology of breast cancer.

This article outlines the current incidence, prevalence, and mortality of breast cancer and reviews the epidemiology of the disease. Major risk factors for the development of breast cancer are covered, including reproductive, genetic, and environmental variables. Understanding the epidemiology of breast cancer will help clinicians identify high-risk patients for appropriate screening and informed disease management decisions.

American College of Surgeons and Surgical Infection Society: Surgical Site Infection Guidelines, 2016 Update

Disclosures outside the scope of this work: Dr. Minei receiv grant support from Irrespet Corp. AtoxBio. Dr. Laronga rec sation for lectures from Genomic Health Inc. and royalties Date. Dr. Jensen is a consultant and paid speaker for Ethico ceives honoraria from CareFusion for their Speaker’s Progr from Irrimax Corp. for consulting and Research Funding honoraria from Surgical Inc. for consultation. Dr. Itani for a multi-institutional study for Sanofi-Pastuer and the Committee Chair. Dr. Dellinger is on the Advisory B Melinta, and Therevance and a grant recipient from Moti trial of iclaprim vs. vancomycin for treatment of skin and so tions. The remaining authors declare no conflicts. Presented at the Surgical Infection Society, Palm Beach, FL

Evaluation of the ProPublica Surgeon Scorecard "Adjusted Complication Rate" Measure Specifications.

Objectives: The ProPublica Surgeon Scorecard is the first nationwide, multispecialty public reporting of individual surgeon outcomes. However, ProPublicas use of a previously undescribed outcome measure (composite of in-hospital mortality or 30-day related readmission) and inclusion of only inpatients have been questioned. Our objectives were to (1) determine the proportion of cases excluded by ProPublicas specifications, (2) assess the proportion of inpatient complications excluded from ProPublicas measure, and (3) examine the validity of ProPublicas outcome measure by comparing performance on the measure to well-established postoperative outcome measures. Methods: Using ACS-NSQIP data (2012–2014) for 8 ProPublica procedures and for All Operations, the proportion of cases meeting all ProPublica inclusion criteria was determined. We assessed the proportion of complications occurring inpatient, and thus not considered by ProPublicas measure. Finally, we compared risk-adjusted performance based on ProPublicas measure specifications to established ACS-NSQIP outcome measure performance (eg, death/serious morbidity, mortality). Results: ProPublicas inclusion criteria resulted in elimination of 82% of all operations from assessment (range: 42% for total knee arthroplasty to 96% for laparoscopic cholecystectomy). For all ProPublica operations combined, 84% of complications occur during inpatient hospitalization (range: 61% for TURP to 88% for total hip arthroplasty), and are thus missed by the ProPublica measure. Hospital-level performance on the ProPublica measure correlated weakly with established complication measures, but correlated strongly with readmission (R2 = 0.834, P < 0.001). Conclusions: ProPublicas outcome measure specifications exclude 82% of cases, miss 84% of postoperative complications, and correlate poorly with well-established postoperative outcomes. Thus, the validity of the ProPublica Surgeon Scorecard is questionable.

Executive Summary of the American College of Surgeons/Surgical Infection Society Surgical Site Infection Guidelines—2016 Update

Guidelines regarding the prevention, detection, and management of surgical site infections (SSIs) have been published previously by a variety of organizations. The American College of Surgeons (ACS)/Surgical Infection Society (SIS) Surgical Site Infection (SSI) Guidelines 2016 Update is intended to update these guidelines based on the current literature and to provide a concise summary of relevant topics.

Exploring Qualitative Perspectives on Surgical Resident Training, Well-Being, and Patient Care

BACKGROUND The Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) trial found no difference in patient outcomes or resident well-being between more restrictive and flexible duty hour policies. Qualitative methods are appropriate for better understanding the experience and perceptions of those affected by duty hour regulations. We conducted a pilot qualitative study on how resident duty hour regulations are perceived by general surgery program directors, surgical residents, and attending surgeons who participated in the FIRST Trial. STUDY DESIGN Semi-structured qualitative interviews were pilot tested with program directors, residents, and attendings to examine initial perceptions of the standard and flexible policies implemented during the trial. The transcribed interviews were analyzed thematically using a constant comparative approach and grouped first by study arm and then by level (patient, surgeon, program, and national). RESULTS More restrictive duty hours were perceived as creating a tension between resident personal and professional well-being. Standard Policy resulted in more transitions, which was perceived as creating vulnerable gaps in patient care. Standard Policy restrictions were seen as particularly challenging for interns and often led to inadequate preparation for promotion and encouraged a shift mentality. CONCLUSIONS In our pilot study, interviewees valued the flexibility afforded in the Flexible Policy arm, as it allowed them to maximize patient safety and educational attainment. Additional qualitative research will expand on program director, resident, and attending perceptions of resident duty hours as well as perceptions of patient safety. Qualitative methods can contribute to the national debate on resident duty hours.

Outcomes of Concurrent Operations: Results From the American College of Surgeons’ National Surgical Quality Improvement Program

Objective: To determine whether concurrently performed operations are associated with an increased risk for adverse events. Background: Concurrent operations occur when a surgeon is simultaneously responsible for critical portions of 2 or more operations. How this practice affects patient outcomes is unknown. Methods: Using American College of Surgeons’ National Surgical Quality Improvement Program data from 2014 to 2015, operations were considered concurrent if they overlapped by ≥60 minutes or in their entirety. Propensity-score-matched cohorts were constructed to compare death or serious morbidity (DSM), unplanned reoperation, and unplanned readmission in concurrent versus non-concurrent operations. Multilevel hierarchical regression was used to account for the clustered nature of the data while controlling for procedure and case mix. Results: There were 1430 (32.3%) surgeons from 390 (77.7%) hospitals who performed 12,010 (2.3%) concurrent operations. Plastic surgery (n = 393 [13.7%]), otolaryngology (n = 470 [11.2%]), and neurosurgery (n = 2067 [8.4%]) were specialties with the highest proportion of concurrent operations. Spine procedures were the most frequent concurrent procedures overall (n = 2059/12,010 [17.1%]). Unadjusted rates of DSM (9.0% vs 7.1%; P < 0.001), reoperation (3.6% vs 2.7%; P < 0.001), and readmission (6.9% vs 5.1%; P < 0.001) were greater in the concurrent operation cohort versus the non-concurrent. After propensity score matching and risk-adjustment, there was no significant association of concurrence with DSM (odds ratio [OR] 1.08; 95% confidence interval [CI] 0.96–1.21), reoperation (OR 1.16; 95% CI 0.96–1.40), or readmission (OR 1.14; 95% CI 0.99–1.29). Conclusions: In these analyses, concurrent operations were not detected to increase the risk for adverse outcomes. These results do not lessen the need for further studies, continuous self-regulation and proactive disclosure to patients.

Should all branch-duct intraductal papillary mucinous neoplasms be resected?

BACKGROUND The relationship between branch-duct intraductal papillary mucinous neoplasms (IPMNs) and malignancy remains controversial and difficult to assess. METHODS Between January 1, 1999 and January 1, 2013, we identified 84 patients with IPMN who underwent resection. RESULTS Preoperatively, 55 patients underwent endoscopic ultrasounds and 58 underwent biopsy. Only 7 lesions were specified preoperatively as branch-duct, which inconsistently correlated with the surgical specimen. Of the 82 patients where the duct was specified, there were 33 malignant lesions. There was no correlation between branch-duct origin and invasive carcinoma. Malignant tumor size did not significantly differ by the duct of origin. Of the 28 patients with invasive carcinoma, branch-duct lesions were significantly associated with the presence of positive lymph nodes, perineural invasion, and lymphovascular invasion. CONCLUSIONS Our study supports the resection criteria for branch-duct IPMN based on size and symptoms. However, it also questions the reliability of our preoperative testing to rule out malignant branch-duct IPMN lesions.

Association of an Enhanced Recovery Pilot With Length of Stay in the National Surgical Quality Improvement Program

Importance Enhanced recovery protocols (ERPs) are standardized care plans of best practices that can decrease morbidity and length of stay (LOS). However, many hospitals need help with implementation. The Enhanced Recovery in National Surgical Quality Improvement Program (ERIN) pilot was designed to support ERP implementation. Objective To evaluate the association of the ERIN pilot with LOS after colectomy. Design, Setting, and Participants Using a difference-in-differences design, pilot LOS before and after ERP implementation was compared with matched controls in a hierarchical model, adjusting for case mix and random effects of hospitals and matched pairs. The setting was 15 hospitals of varied size and academic status from the National Surgical Quality Improvement Program. Preimplementation and postimplementation colectomy cases (July 1, 2013, to December 31, 2015) were collected using novel ERIN variables. Emergency and septic cases were excluded. A propensity score match identified a 2:1 control cohort of patients undergoing colectomy at non-ERIN hospitals. Interventions Pilot hospitals developed and implemented ERPs that included expert guidance, multidisciplinary teams, data audits, and opportunities for collaboration. Main Outcomes and Measures The primary outcome was LOS, and the secondary outcome was serious morbidity or mortality composite. Results There were 4975 colectomies performed by 15 ERIN pilot hospitals (3437 before implementation and 1538 after implementation) compared with a control cohort of 9950 colectomies (4726 before implementation and 5224 after implementation). The mean LOS decreased by 1.7 days in the pilot (6.9 [interquartile range (IQR), 4-8] days before implementation vs 5.2 [IQR, 3-6] days after implementation, P < .001) compared with 0.4 day in controls (6.4 [IQR, 4-7] days before implementation vs 6.0 [IQR, 3-7] days after implementation, P < .001). Readmission did not differ pre-post for the pilot or controls. Serious morbidity or mortality decreased for pilot participants (485 [14.1%] before implementation vs 162 [10.5%] after implementation, P < .001), with no difference in controls, and remained significant after risk adjustment (adjusted odds ratio, 0.76; 95% CI, 0.60-0.96). After adjusting for differences in case mix and for clustering in hospitals and matched pairs, the adjusted difference-in-differences model demonstrated a decrease in LOS by 1.1 days in the pilot over controls (P < .001). Conclusions and Relevance Participating ERIN pilot hospitals achieved shorter LOS and decreased complications after elective colectomy, without increasing readmissions. The ability to implement ERPs across hospitals of varied size and resources is essential. Lessons from the ERIN pilot may inform efforts to scale this effective and evidence-based intervention.

Concurrent bariatric operations and association with perioperative outcomes: registry based cohort study

Objective To determine whether perioperative outcomes differ between patients undergoing concurrent compared with non-concurrent bariatric operations in the USA. Design Retrospective, propensity score matched cohort study. Setting Hospitals in the US accredited by the American College of Surgeons’ metabolic and bariatric surgery accreditation and quality improvement program. Participants 513 167 patients undergoing bariatric operations between 1 January 2014 and 31 December 2016. Main outcome measures The primary outcome measure was a composite of 30 day death, morbidity, readmission, reoperation, anastomotic or staple line leak, and bleeding events. Operative duration and lengths of stay were also assessed. Operations were defined as concurrent if they overlapped by 60 or more minutes or in their entirety. Results In this study of 513 167 operations, 739 (29.5%) surgeons at 483 (57.8%) hospitals performed 6087 (1.2%) concurrent operations. The most frequently performed concurrent bariatric operations were sleeve gastrectomy (n=3250, 53.4%) and Roux-en-Y gastric bypass (n=1601, 26.3%). Concurrent operations were more often performed at large academic medical centers with higher operative volumes and numbers of trainees and by higher volume surgeons. Compared with non-concurrent operations, concurrent operations lasted a median of 34 minutes longer (P<0.001) and resulted in 0.3 days longer average length of stay (P<0.001). Perioperative adverse events were not observed to more likely occur in concurrent compared with non-concurrent operations (7.5% v 7.4%; relative risk 1.02, 95% confidence interval 0.90 to 1.15; P=0.84). Conclusions Concurrent bariatric operations occurred infrequently, but when they did, there was no observable increased risk for adverse perioperative outcomes compared with non-concurrent operations. These results, however, do not argue against improved and more meaningful disclosure of concurrent surgery practices.

Is Health Services Research Important for Surgeons

Kristen A. Ban, MD, Karl Y. Bilimoria, MD, MS* Division of Research and Optimal Patient Care, American College of Surgeons, 633 North St. Clair Street, 22nd Floor, Chicago, IL 60611, USA; Department of Surgery, Loyola University Medical Center, 2160 South 1st Avenue, Maywood, IL 60153, USA; Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, 633 North St. Clair Street, 20th Floor, Chicago, IL 60611, USA; Center forHealthcare Studies, Feinberg School of Medicine, Northwestern University, 633 North St. Clair Street, 20th Floor, Chicago, IL 60611, USA