Ravi Rajaram

Association of the 2011 ACGME resident duty hour reform with general surgery patient outcomes and with resident examination performance.

IMPORTANCE In 2011, the Accreditation Council for Graduate Medical Education (ACGME) restricted resident duty hour requirements beyond those established in 2003, leading to concerns about the effects on patient care and resident training. OBJECTIVE To determine if the 2011 ACGME duty hour reform was associated with a change in general surgery patient outcomes or in resident examination performance. DESIGN, SETTING, AND PARTICIPANTS Quasi-experimental study of general surgery patient outcomes 2 years before (academic years 2009-2010) and after (academic years 2012-2013) the 2011 duty hour reform. Teaching and nonteaching hospitals were compared using a difference-in-differences approach adjusted for procedural mix, patient comorbidities, and time trends. Teaching hospitals were defined based on the proportion of cases at which residents were present intraoperatively. Patients were those undergoing surgery at hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP). General surgery resident performance on the annual in-training, written board, and oral board examinations was assessed for this same period. EXPOSURES National implementation of revised resident duty hour requirements on July 1, 2011, in all ACGME accredited residency programs. MAIN OUTCOMES AND MEASURES Primary outcome was a composite of death or serious morbidity; secondary outcomes were other postoperative complications and resident examination performance. RESULTS In the main analysis, 204,641 patients were identified from 23 teaching (n = 102,525) and 31 nonteaching (n = 102,116) hospitals. The unadjusted rate of death or serious morbidity improved during the study period in both teaching (11.6% [95% CI, 11.3%-12.0%] to 9.4% [95% CI, 9.1%-9.8%], P < .001) and nonteaching hospitals (8.7% [95% CI, 8.3%-9.0%] to 7.1% [95% CI, 6.8%-7.5%], P < .001). In adjusted analyses, the 2011 ACGME duty hour reform was not associated with a significant change in death or serious morbidity in either postreform year 1 (OR, 1.12; 95% CI, 0.98-1.28) or postreform year 2 (OR, 1.00; 95% CI, 0.86-1.17) or when both postreform years were combined (OR, 1.06; 95% CI, 0.93-1.20). There was no association between duty hour reform and any other postoperative adverse outcome. Mean (SD) in-training examination scores did not significantly change from 2010 to 2013 for first-year residents (499.7 [ 85.2] to 500.5 [84.2], P = .99), for residents from other postgraduate years, or for first-time examinees taking the written or oral board examinations during this period. CONCLUSIONS AND RELEVANCE Implementation of the 2011 ACGME duty hour reform was not associated with a change in general surgery patient outcomes or differences in resident examination performance. The implications of these findings should be considered when evaluating the merit of the 2011 ACGME duty hour reform and revising related policies in the future.

Concerns About Using the Patient Safety Indicator-90 Composite in Pay-for-Performance Programs

In 2003, the Agency for Healthcare Research and Quality (AHRQ) released 20 patient safety indicators (PSI) to facilitate measurement of adverse events. Though intended for internal quality measurement and improvement, several PSIs are now being widely publicly reported, including on the Centers for Medicare & Medicaid’s (CMS’s) Hospital Compare website. Additionally, on October 1, 2014 (fiscal year 2015), CMS began using AHRQ’s Patient Safety for Selected Indicators (PSI90) as a core metric in 2 of its pay-for-performance programs: the Hospital-Acquired Condition (HAC) Reduction program and the Hospital Value-Based Purchasing (VBP) program. PSI-90 is a composite measure consisting of 8 weighted component PSI measures (Table).1 In the HAC Reduction program, PSI-90 is responsible for 35% of the overall score, and the poorest-performing hospital quartile will have their CMS payments reduced by up to 1% (~

Evaluation of Initial Participation in Public Reporting of American College of Surgeons NSQIP Surgical Outcomes on Medicare's Hospital Compare Website

330 million). In the Hospital VBP Program, CMS will reallocate 1.5% (~

National evaluation of hospital readmission after pulmonary resection

1.4 billion) of its diagnosis related group payments to hospitals according to their overall score, 30% of which is composed of PSI-90 and 4 other outcome measures. Thus, the PSI-90 composite measure has been given substantial weight in attempting to align the financial interests of hospitals with the quality of care they provide. As evidenced by a lack of continued maintenance endorsement from the National Quality Forum in 2014, numerous problems exist with the current PSI-90 composite measure: (1) flawed component measures; (2) clinical areas targeted; (3) accuracy of adverse events identified; (4) adequacy of the risk adjustment; and (5) formulation of the composite measure. These flaws may incorrectly identify problem areas for hospitals to address, unfairly penalize hospitals financially, and adversely influence clinician engagement in quality improvement. However, there are opportunities to improve this measure in hopes of more accurately monitoring hospital performance for potentially preventable complications.

Association of the 2011 ACGME Resident Duty Hour Reform with Postoperative Patient Outcomes in Surgical Specialties

Background In October 2012, The Centers for Medicare and Medicaid Services (CMS) began publicly reporting American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) surgical outcomes on its public reporting website, Hospital Compare. Participation in this CMS-NSQIP initiative is voluntary. Our objective was to compare CMS-NSQIP participating hospitals to ACS NSQIP hospitals that elected not to participate. Study Design Hospital Compare and American Hospital Association Annual Survey data were merged to compare CMS-NSQIP participants to non-participants. Regression models were developed to assess predictors of participation and to assess if hospitals differed on 32 process, 10 patient experience (HCAHPS), and 16 outcome (Hospital Compare & AHRQ) measures. Additionally, performance on two waves of publicly reported ACS NSQIP surgical outcome measures was compared. Results Of the 452 ACS NSQIP hospitals, 80 (18%) participated in CMS-NSQIP public reporting. Participating hospitals had more beds, admissions, operations, and were more often accredited (Commission on Cancer and the Council of Teaching Hospitals (COTH) (P<0.05). Only COTH membership remained significant in adjusted analyses (OR 2.45, 95% CI 1.12–5.35). Hospital performance on process, HCAHPS, and outcome measures were not associated with CMS-NSQIP participation for 54 of 58 measures examined. Hospitals with “better-than-average” performance were more likely to publicly report the Elderly Surgery measure (P<0.05). In wave two, an increased proportion of new participants reported “worse-than-average” outcomes. Conclusions There were few measurable differences between CMS-NSQIP participating and non-participating hospitals. The decision to voluntarily publicly report may be related to the hospital’s culture of quality improvement and transparency.

Use and Underlying Reasons for Duty Hour Flexibility in the Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) Trial

OBJECTIVES Our objectives were to (1) assess readmission rates and timing after pulmonary resection, (2) report the most common reasons for rehospitalization, and (3) identify risk factors for unplanned readmission after pulmonary resection. METHODS Patients who underwent pulmonary resection were identified from the 2011 American College of Surgeons National Surgical Quality Improvement Program database. We examined readmission within 30 days of surgery for all resections and 3 subgroups: open lobectomy, video-assisted thoracoscopic lobectomy, and pneumonectomy. Regression models were developed to identify factors associated with readmission. RESULTS In 1847 patients, there were 899 open lobectomies (49%), 724 video-assisted thoracoscopic lobectomies (39%), and 85 pneumonectomies (5%). The overall readmission rate was 9.3% with no significant difference found among patients undergoing open lobectomy (9.1%), video-assisted thoracoscopic lobectomy (8.4%), or pneumonectomy (11.8%) (P = .576). The median time from operation to readmission was similar among patients undergoing open (14 days) or video-assisted thoracoscopic lobectomy (13 days). The most common cause of readmission for all groups examined was pulmonary related. In multivariable analyses, the strongest factor associated with readmission was an inpatient complication after the initial surgery in all resections (hazard ratio [HR], 4.29; 95% confidence interval [CI], 3.05-6.04), open lobectomy (HR, 4.36; 95% CI, 2.75-6.94), and video-assisted thoracoscopic lobectomy (HR, 4.60; 95% CI, 2.65-7.97). Surgical approach was not associated with readmission (video-assisted thoracoscopic vs open lobectomy: HR, 1.07; 95% CI, 0.75-1.52). CONCLUSIONS Experiencing a postoperative complication was strongly associated with unplanned readmission. Increased attention toward reducing postoperative complications and earlier outpatient follow-up in these patients may be a viable strategy for decreasing readmissions after pulmonary resection.

Impact of the 2011 ACGME resident duty hour reform on hospital patient experience and processes-of-care

BACKGROUND The 2011 ACGME resident duty hour reform implemented additional restrictions to existing duty hour policies. Our objective was to determine the association between this reform and patient outcomes among several surgical specialties. STUDY DESIGN Patients from 5 surgical specialties (neurosurgery, obstetrics/gynecology, orthopaedic surgery, urology, and vascular surgery) were identified from the American College of Surgeons NSQIP. Data from 1 year before and 2 years after the reform was implemented were obtained for teaching and nonteaching hospitals. Hospital teaching status was defined based on the percentage of operations with a resident present intraoperatively. Difference-in-differences models were developed separately for each specialty and adjusted for patient demographics, comorbidities, procedural case-mix, and time trends. The association between duty hour reform and a composite measure of death or serious morbidity within 30 days of surgery was estimated for each specialty. RESULTS The unadjusted rate of death or serious morbidity decreased during the study period in both teaching and nonteaching hospitals for all surgical specialties. In multivariable analyses, there were no significant associations between duty hour reform and the composite outcomes of death or serious morbidity in the 2 years post-reform for any surgical specialty evaluated (neurosurgery: odds ratio [OR] = 0.90; 95% CI, 0.75-1.08; p = 0.26; obstetrics/gynecology: OR = 0.96; 95% CI, 0.71-1.30; p = 0.80; orthopaedic surgery: OR = 0.95; 95% CI, 0.74-1.22; p = 0.70; urology: OR = 1.16; 95% CI, 0.89-1.51; p = 0.26; vascular surgery: OR = 1.07; 95% CI, 0.93-1.22; p = 0.35). CONCLUSIONS Implementation of the 2011 ACGME resident duty hour reform was not associated with a significant change in patient outcomes for several surgical specialties in the 2 years after reform.

Assessment of non‐surgical versus surgical therapy for localized hepatocellular carcinoma

BACKGROUND The Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) Trial randomly assigned surgical residency programs to either standard duty hour policies or flexible policies that eliminated caps on shift lengths and time off between shifts. Our objectives were to assess adherence to duty hour requirements in the Standard Policy arm and examine how often and why duty hour flexibility was used in the Flexible Policy arm. STUDY DESIGN A total of 3,795 residents in the FIRST trial completed a survey in January 2016 (response rate >95%) that asked how often and why they exceeded current standard duty hour limits in both study arms. RESULTS Flexible Policy interns worked more than 16 hours continuously at least once in a month more frequently than Standard Policy residents (86% vs 37.8%). Flexible Policy residents worked more than 28 hours once in a month more frequently than Standard Policy residents (PGY1: 64% vs 2.9%; PGY2 to 3: 62.4% vs 41.9%; PGY4 to 5: 52.2% vs 36.6%), but this occurred most frequently only 1 to 2 times per month. Although residents reported working more than 80 hours in a week 3 or more times in the most recent month more frequently under Flexible Policy vs Standard Policy (19.9% vs 16.2%), the difference was driven by interns (30.9% vs 19.6%), and there were no significant differences in exceeding 80 hours among PGY2 to 5 residents. The most common reasons reported for extending duty hours were facilitating care transitions (76.6%), stabilizing critically ill patients (70.7%), performing routine responsibilities (67.9%), and operating on patients known to the trainee (62.0%). CONCLUSIONS There were differences in duty hours worked by residents in the Flexible vs Standard Policy arms of the FIRST trial, but it appeared that residents generally used the flexibility for patient care and educational opportunities selectively.

Risk prediction tools in surgical oncology

Introduction In 2011, the Accreditation Council for Graduate Medical Education (ACGME) expanded restrictions on resident duty hours. While studies have shown no association between these restrictions and improved outcomes, process-of-care and patient experience measures may be more sensitive to resident performance, and thus may be impacted by duty hour policies. The objective of this study was to evaluate the association between the 2011 resident duty hour reform and measures of processes-of-care and patient experience. Methods Hospital Consumer Assessment of Healthcare Providers and Systems survey data and process-of-care scores were obtained from the Centers for Medicare and Medicaid Services Hospital Compare website for 1 year prior to (1 July 2010 to 30 June 2011) and 1 year after (1 July 2011 to 30 June 2012) duty hour reform implementation. Using a difference-in-differences model, non-teaching and teaching hospitals were compared before and after the 2011 reform to test the association of this policy with changes in process-of-care and patient experience measure scores. Results Duty hour reform was not associated with a change in the five patient experience measures evaluated, including patients rating a hospital 9 or 10 (coefficient −0.003, 95% CI −0.79 to 0.79) or stating they would ‘definitely recommend’ a hospital (coefficient −0.28, 95% CI −1.01 to 0.44). For all 10 process-of-care measures examined, such as antibiotic timing (coefficient −0.462, 95% CI −1.502 to 0.579) and discontinuation (0.188, 95% CI −0.529 to 0.904), duty hour reform was not associated with a change in scores. Conclusions The 2011 ACGME duty hour reform was not associated with improvements in process-of-care and patient experience measures. These data should be considered when considering reform of resident duty hour policies.

Association Between Hospital Characteristics and Performance on the New Hospital-Acquired Condition Reduction Program’s Surgical Site Infection Measures

Localized hepatocellular carcinoma (HCC) in patients with adequate liver function is typically treated with resection. Non‐surgical modalities including trans‐arterial embolization have emerged as options for intermediate/advanced HCC. Hypothesizing that non‐surgical techniques have expanded to localized disease, we examined treatment patterns, factors associated with surgical therapy, and the impact of modality on survival.