Publications by authors named "David D Odell"

83 Publications

Lung Cancer Strategist Program: A novel care delivery model to improve timeliness of diagnosis and treatment in high-risk patients.

Healthc (Amst) 2021 Jun 26;9(3):100563. Epub 2021 Jun 26.

Division of Thoracic Surgery, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA. Electronic address:

Introduction: The diagnosis and treatment of lung cancer is challenged by complex diagnostic pathways and fragmented care that can lead to care disparities for vulnerable patients.

Methods: A multi-institutional, multidisciplinary conference was convened to address the complexity of lung cancer care particularly in patients at high-risk for treatment delay. The resulting care delivery model, called the Lung Cancer Strategist Program (LCSP), was led by a thoracic-trained advanced practice provider (APP) with emphasis on expedited surgery and early oncologic consultation in the assessment of a newly diagnosed suspicious lung nodule. We performed a retrospective review to evaluate care efficiency and oncologic outcomes in the first 100 LCSP patients compared to 100 concurrent patients managed via routine surgical referral.

Results: In the 78 LCSP and 41 routine referral patients managed via nodule surveillance, LCSP patients had a shorter time from suspicious finding to work-up (3 vs. 26 days, p < 0.001) and to surveillance decision (12.5 vs. 39 days, p < 0.001). In the 22 LCSP and 59 routine referral patients treated for intrathoracic malignancy, LCSP patients had fewer hospital visits (4 vs 6, p < 0.001), clinicians seen (1.5 vs. 2, p = 0.08), and diagnostic studies (4 vs 5, p = 0.01) with a shorter time to diagnosis (30.5 vs. 48 days, p = 0.02) and treatment (40.5 vs. 68.5 days, p = 0.02).

Conclusions: Patient triage through a thoracic-trained APP in consultation with surgical, medical, and radiation oncology facilitates rapid assessment of benign versus malignant lesions with reduced time to diagnosis and treatment, even among patients at high-risk for treatment delay.
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http://dx.doi.org/10.1016/j.hjdsi.2021.100563DOI Listing
June 2021

Institutional factors associated with adherence to quality measures for stage I and II non-small cell lung cancer.

J Thorac Cardiovasc Surg 2020 Jul 29. Epub 2020 Jul 29.

Surgical Outcomes and Quality Improvement Center, Department of Surgery and Center for Healthcare Studies, Northwestern University Feinberg School of Medicine, Chicago, Ill; Northwestern Institute for Comparative Effectiveness Research in Oncology, Northwestern University Feinberg School of Medicine, Chicago, Ill. Electronic address:

Objective: Although previous studies have identified variation in quality lung cancer care, existing quality metrics may not fully capture the complexity of cancer care. The Thoracic Surgery Outcomes Research Network recently developed quality measures to address this. We evaluated baseline adherence to these measures and identified factors associated with adherence.

Methods: Patients with pathologic stage I and II non-small cell lung cancer from 2010 to 2015 were identified in the National Cancer Database. Patient-level and hospital-level adherence to 7 quality measures was calculated. Goal hospital adherence threshold was 85%. Factors influencing adherence were identified using multilevel logistic regression.

Results: We identified 253,182 patients from 1324 hospitals. Lymph node sampling was performed in 91% of patients nationally, but only 76% of hospitals met the 85% adherence mark. Similarly, 89% of T1b (seventh edition staging) tumors had anatomic resection, with 69% hospital-level adherence. Sixty-nine percent of pathologic stage II patients were recommended chemotherapy, with only 23% hospitals adherent. Eighty-three percent of patients had biopsy before primary radiation, with 64% hospitals adherent. Higher volume and academic institutions were associated with nonadherence to adjuvant chemotherapy and radiation therapy measures. Conversely, lower volume and nonacademic institutions were associated with inadequate nodal sampling and nonanatomic resection.

Conclusions: Significant gaps continue to exist in the delivery of quality care to patients with early-stage lung cancer. High-volume academic hospitals had higher adherence for surgical care measures, but lower rates for coordination of care measures. This requires further investigation, but suggests targets for quality improvement may vary by institution type.
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http://dx.doi.org/10.1016/j.jtcvs.2020.05.123DOI Listing
July 2020

Association of preoperative smoking with complications following major gastrointestinal surgery.

Am J Surg 2021 Jun 7. Epub 2021 Jun 7.

Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern Medicine, Chicago, IL, USA.

Background: Understanding modifiable surgical risk factors is essential for preoperative optimization. We evaluated the association between smoking and complications following major gastrointestinal surgery.

Methods: Patients who underwent elective colorectal, pancreatic, gastric, or hepatic procedures were identified in the 2017 ACS NSQIP dataset. The primary outcome was 30-day death or serious morbidity (DSM). Secondary outcomes included pulmonary complications, wound complications, and readmission. Multivariable logistic regression was used to evaluate the association between smoking and these outcomes.

Results: A total of 46,921 patients were identified, of whom 7,671 (16.3%) were smokers. Smoking was associated with DSM (23.2% vs. 20.4%, OR 1.15 [1.08-1.23]), wound complications (13.0% vs. 10.4%, OR 1.24 [1.14-1.34]), pulmonary complications (4.9% vs 2.9%, OR 1.93 [1.70-2.20]), and unplanned readmission (12.6% vs. 11%, OR 1.14 [95% CI 1.06-1.23]).

Conclusions: Smoking is associated with complications following major gastrointestinal surgery. Patients who smoke should be counseled prior to surgery regarding risks.
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http://dx.doi.org/10.1016/j.amjsurg.2021.06.002DOI Listing
June 2021

The Unfulfilled Need for Technical Skill Assessments among Academic Cardiothoracic Surgeons.

Semin Thorac Cardiovasc Surg 2021 Jun 2. Epub 2021 Jun 2.

Division of Thoracic Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA; Surgical Outcomes and Quality Improvement Center, Northwestern University Feinberg School of Medicine, Chicago, IL, USA. Electronic address:

Objective: Technical skill is a proven predictor of surgical outcomes, yet no platform exists for continual technical skill development following training. We aim to characterize the perceived need for feedback on technical skill among practicing thoracic surgeons.

Methods: Under the Thoracic Education Cooperative Group (TECoG), a panel of cardiothoracic surgeons and trainees developed and distributed an online survey for cardiothoracic surgery faculty in the Thoracic Surgery Directors Association (TSDA) database. The survey solicited demographics, perceived need for constructive feedback, barriers to sharing critiques, and preferences of desired peer reviewers.

Results: 140 surgeons responded to our survey (response rate: 19.6% (140/713)). Most respondents had practiced for greater than 15 years (49.3%, 69/140). 76.4% (107/140) of responders agreed or strongly agreed receiving feedback on their technical skills would help them improve, and 71.5% (100/140) desired individualized skills feedback. While 61.4% (86/140) of surgeons received meaningful technical skill feedback as attending surgeons, this was infrequent, with 63.3% (88/139) last receiving feedback over 12 months prior. Commonly cited barriers to sharing feedback included lack of common practice, time constraints, and hierarchical barriers. 66.2% (92/139) of participants would spend at least 10 minutes providing peer feedback to receive feedback on their own skills, while 45.3% (63/139) would spend greater than 20 minutes.

Conclusions: Attending thoracic surgeons identify an unmet desire for ongoing, constructive feedback on their technical skills following training. Surgeons feel critique fosters improvement and would devote significant time to engaging in peer feedback. A platform for exchange of technical skill feedback is warranted.
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http://dx.doi.org/10.1053/j.semtcvs.2021.05.016DOI Listing
June 2021

Administrative and clinical databases: General thoracic surgery perspective on approaches and pitfalls.

J Thorac Cardiovasc Surg 2021 Mar 19. Epub 2021 Mar 19.

Department of Surgery, Surgical Outcomes and Quality Improvement Center, Northwestern University Feinberg School of Medicine, Chicago, Ill.

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http://dx.doi.org/10.1016/j.jtcvs.2021.03.057DOI Listing
March 2021

Entrustable Professional Activity-Based Summative Performance Assessment in the Surgery Clerkship.

J Surg Educ 2021 Jul-Aug;78(4):1144-1150. Epub 2020 Dec 29.

Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago Illinois. Electronic address:

Objective: The objectives of this study were to 1) assess the performance Entrustable Professional Activities (EPAs) when integrated into the summative assessment of third-year medical students on the surgery clerkship and 2) to compare EPAs to traditional clinical performance assessment tools.

Design: EPA assessments were collected prospectively from a minimum of 4 evaluators at the completion of each surgical clerkship rotation from November 2019 to June 2019. Overall EPA-based clinical performance scores were calculated as the sum of the mean EPA score from each evaluator. A rating of overall clinical performance called the clinical performance appraisal (CPA) was also collected. EPA ratings were compared to the CPA score, National Board of Medical Examiners exam score, objective structured clinical exam scores, and final clerkship grade.

Setting: Northwestern Memorial Hospital, a tertiary care teaching institution in Chicago, IL.

Results: Overall, 446 evaluations (111 students) were included in the analysis. The aggregate EPA scores ranged from 11.6-24.0 (mean 19.9 ± 2.0), and the CPA scores ranged from 4.4-9.0 (mean 7.6 ± 0.7). The variance among learners in EPA scores was significantly higher than CPA scores (p < 0.001). The aggregate EPA scores correlated well with CPA scores (Spearman's rho 0.803) but had lesser, positive correlations with the objective structured clinical exam (rho 0.153) and National Board of Medical Examiners (rho 0.265) scores. When all EPA scores were included in ordinal logistic regression, only EPA 6, oral presentation of patients, was independently associated with students' final grades (OR: 10.05, 95%CI 1.41-71.80; p = 0.02).

Conclusion: Integration of EPAs for use in clinical performance assessment of medical students is feasible within a surgery clerkship. Compared to a global clinical performance assessment, EPA-based assessment provided better discrimination of clinical performance among learners. Use of EPAs may better identify advanced learners and those that need additional time.
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http://dx.doi.org/10.1016/j.jsurg.2020.12.001DOI Listing
June 2021

Comparative Effectiveness of Surgical Approaches for Lung Cancer.

J Surg Res 2021 Jul 9;263:274-284. Epub 2020 Dec 9.

Division of Thoracic Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois. Electronic address:

Background: The magnitude of association and quality of evidence comparing surgical approaches for lung cancer resection has not been analyzed. This has resulted in conflicting information regarding the relative superiority of the different approaches and disparate opinions on the optimal surgical treatment. We reviewed and systematically analyzed all published data comparing near- (30-d) and long-term mortality for minimally invasive to open surgical approaches for lung cancer.

Methods: Comprehensive search of EMBASE, MEDLINE, and the Cochrane Library, from January 2009 to August 2019, was performed to identify the studies and those that passed bias assessment were included in the analysis utilizing propensity score matching techniques. Meta-analysis was performed using random-effects and fixed-effects models. Risk of bias was assessed via the Newcastle-Ottawa Scale and the ROBINS-I tool. The study was registered in PROSPERO (CRD42020150923) prior to analysis.

Results: Overall, 1382 publications were identified but 19 studies were included encompassing 47,054 patients after matching. Minimally invasive techniques were found to be superior with respect to near-term mortality in early and advanced-stage lung cancer (risk ratio 0.45, 95% confidence interval [CI] 0.21-0.95, I = 0%) as well as for elderly patients (odds ratio 0.45, 95% CI 0.31-0.65, I = 30%), but did not demonstrate benefit for high-risk patients (odds ratio 0.74, 95% CI 0.06-8.73, I = 78%). However, no difference was found in long-term survival.

Conclusions: We performed the first systematic review and meta-analysis to compare surgical approaches for lung cancer which indicated that minimally invasive techniques may be superior to thoracotomy in near-term mortality, but there is no difference in long-term outcomes.
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http://dx.doi.org/10.1016/j.jss.2020.10.020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8169528PMC
July 2021

Consensus for Thoracoscopic Left Upper Lobectomy-Essential Components and Targets for Simulation.

Ann Thorac Surg 2021 Aug 27;112(2):436-442. Epub 2020 Oct 27.

Division of Thoracic Surgery, New York-Presbyterian Hospital, Weill Cornell Medical College, New York, New York.

Background: Simulation-based training is a valuable component of cardiothoracic surgical education. Effective curriculum development requires consensus on procedural components and focused attention on specific learning objectives. Through use of a Delphi process, we established consensus on the steps of video-assisted thoracoscopic surgery (VATS) left upper lobectomy and identified targets for simulation.

Methods: Experienced thoracic surgeons were randomly selected for participation. Surgeons voted and commented on the necessity of individual steps comprising VATS left upper lobectomy. Steps with greater than 80% of participants in agreement of their necessity were determined to have established "consensus." Participants voted on the physical or cognitive complexity of each, or both, and chose steps most amenable to focused simulation.

Results: Thirty thoracic surgeons responded and joined in the voting process. Twenty operative steps were identified, with surgeons reaching consensus on the necessity of 19. Components deemed most difficult and amenable to simulation included those related to dissection and division of the bronchus, artery, and vein.

Conclusions: Through a Delphi process, surgeons with a variety of practice patterns can achieve consensus on the operative steps of left upper lobectomy and agreement on those most appropriate for simulation. This information can be implemented in the development of targeted simulation for VATS lobectomy.
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http://dx.doi.org/10.1016/j.athoracsur.2020.06.152DOI Listing
August 2021

"Are We Gonna Talk About It or Not?" Thoracic Oncology Provider Perspectives on Smoking Cessation.

J Surg Res 2021 02 12;258:422-429. Epub 2020 Oct 12.

Northwestern University Feinberg School of Medicine, Chicago, Illinois; Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery and Center for Healthcare Studies, Northwestern University Feinberg School of Medicine, Chicago, Illinois. Electronic address:

Background: Tobacco use is the greatest preventable cause of death and disease in the United States. Despite recommendations from the Centers for Disease Control and Prevention, United States Preventive Task Force, and major professional societies that all health-care providers provide smoking-cessation counseling, smoking-cessation interventions are not consistently delivered in clinical practice. We sought to identify important barriers and facilitators to the utilization of smoking-cessation interventions in a thoracic oncology program.

Materials And Methods: We conducted 14 semistructured interviews with providers including thoracic surgeons (n = 3), interventional pulmonologists (n = 1), medical oncologists (n = 3), radiation oncologists (n = 2), and nurses (n = 5). Interviewees were asked about prior and current smoking-cessation efforts, their perspectives on barriers to successful smoking cessation, and opportunities for improvement. Responses were analyzed inductively to identify common themes.

Results: All interviewees report discussing smoking cessation with their patients and realize the importance of a smoking-cessation counseling; however, smoking-cessation interventions are inconsistent and often lacking. Providers emphasized five domains that impact their delivery of smoking-cessation interventions: patient willingness and motivation to quit, clinical engagement and follow-up, documentation of smoking history, provider education in smoking cessation, and the availability of additional smoking-cessation resources.

Conclusions: Providers recognize the need for more efficient and consistent smoking-cessation interventions. Therefore, the development of interventions that address this need would not only be easily taught to providers and delivered to patients but also be welcomed into clinics.
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http://dx.doi.org/10.1016/j.jss.2020.08.058DOI Listing
February 2021

In Reply.

Authors:
David D Odell

Acad Med 2020 10;95(10):1467

Associate professor, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois;

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http://dx.doi.org/10.1097/ACM.0000000000003602DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7566685PMC
October 2020

The Art and Science of Mentorship in Cardiothoracic Surgery: A Systematic Review of the Literature.

Ann Thorac Surg 2020 Aug 25. Epub 2020 Aug 25.

Background: As academic cardiothoracic surgeons focus on producing a new generation of successful surgeon leaders, mentorship has emerged as one of the most important variables influencing professional and personal success and satisfaction. We explore the literature to determine the benefits, qualities and features of the mentor relationship.

Methods: A comprehensive review was performed in February for 2020 of Ovid MEDLINE, Cochrane Central Register of Controlled Trials, and the SCOPUS Database using 'mentor' as a primary search term. The titles and abstracts of these publications were then reviewed by 2 of the authors to identify relevant sources addressing topics related to mentorship in cardiothoracic surgery and identify 4 specific areas of focus (1) the value of mentorship, (2) the skills needed to be an effective mentor, (3) effective approaches for identifying and receiving mentorship, and (4) the unique considerations associated with mentorship for traditionally underrepresented populations in surgery.

Results: Of 16,469 articles reviewed, 167 relevant manuscripts were identified and 62 were included.

Conclusions: There is undeniable value in mentorship when navigating a career in cardiothoracic surgery. By sharing the most significant features and skills of both ideal mentors and mentees, we hope to provide a framework to improve the quality of mentorship from both sides.
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http://dx.doi.org/10.1016/j.athoracsur.2020.06.051DOI Listing
August 2020

Association Between Implementing Comprehensive Learning Collaborative Strategies in a Statewide Collaborative and Changes in Hospital Safety Culture.

JAMA Surg 2020 10;155(10):934-940

Illinois Surgical Quality Improvement Collaborative (ISQIC), Chicago.

Importance: Hospital safety culture remains a critical consideration when seeking to reduce medical errors and improve quality of care. Little is known regarding whether participation in a comprehensive, multicomponent, statewide quality collaborative is associated with changes in hospital safety culture.

Objective: To examine whether implementation of a comprehensive, multicomponent, statewide surgical quality improvement collaborative is associated with changes in hospital safety culture.

Design, Setting, And Participants: In this survey study, the Safety Attitudes Questionnaire, a 56-item validated survey covering 6 culture domains (teamwork, safety, operating room safety, working conditions, perceptions of management, and employee engagement), was administered to a random sample of physicians, nurses, operating room staff, administrators, and leaders across Illinois hospitals to assess hospital safety culture prior to launching a new statewide quality collaborative in 2015 and then again in 2017. The final analysis included 1024 respondents from 36 diverse hospitals, including major academic, community, and rural centers, enrolled in ISQIC (Illinois Surgical Quality Improvement Collaborative).

Exposures: Participation in a comprehensive, multicomponent statewide surgical quality improvement collaborative. Key components included enrollment in a common standardized data registry, formal quality and process improvement training, participation in collaborative-wide quality improvement projects, funding support for local projects, and guidance provided by surgeon mentors and process improvement coaches.

Main Outcomes And Measures: Perception of hospital safety culture.

Results: The overall survey response rate was 43.0% (580 of 1350 surveys) in 2015 and 39.0% (444 of 1138 surveys) in 2017 from 36 hospitals. Improvement occurred in all the overall domains, with significant improvement in teamwork climate (change, 3.9%; P = .03) and safety climate (change, 3.2%; P = .02). The largest improvements occurred in individual measures within domains, including physician-nurse collaboration (change, 7.2%; P = .004), reporting of concerns (change, 4.7%; P = .009), and reduction in communication breakdowns (change, 8.4%; P = .005). Hospitals with the lowest baseline safety culture experienced the largest improvements following collaborative implementation (change range, 11.1%-14.9% per domain; P < .05 for all). Although several hospitals experienced improvement in safety culture in 1 domain, most hospitals experienced improvement across several domains.

Conclusions And Relevance: This survey study found that hospital enrollment in a statewide quality improvement collaborative was associated with overall improvement in safety culture after implementing multiple learning collaborative strategies. Hospitals with the poorest baseline culture reported the greatest improvement following implementation of the collaborative.
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http://dx.doi.org/10.1001/jamasurg.2020.2842DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7424544PMC
October 2020

A National Mixed-Methods Evaluation of Preparedness for General Surgery Residency and the Association With Resident Burnout.

JAMA Surg 2020 09;155(9):851-859

Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.

Importance: Differences in medical school experiences may affect how prepared residents feel themselves to be as they enter general surgery residency and may contribute to resident burnout.

Objectives: To assess preparedness for surgical residency, to identify factors associated with preparedness, to examine the association between preparedness and burnout, and to explore resident and faculty perspectives on resident preparedness.

Design, Setting, And Participants: This cross-sectional study used convergent mixed-methods analysis of data from a survey of US general surgery residents delivered at the time of the 2017 American Board of Surgery In-Training Examination (January 26 to 31, 2017) in conjunction with qualitative interviews of residents and program directors conducted as part of the Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) trial. A total of 262 Accreditation Council for Graduate Medical Education-approved US general surgery residency programs participated. Survey data were collected from 3693 postgraduate year (PGY) 1 and PGY2 surgical residents (response rate, 99%) and 98 interviews were conducted with residents and faculty from September 1 to December 15, 2018. Data were analyzed from June 1, 2017, to February 15, 2018.

Main Outcomes And Measures: Hierarchical regression models were developed to examine factors associated with preparedness and to assess the association between preparedness and resident burnout. Qualitative interviews were conducted to identify themes associated with preparation for residency.

Results: Of the 3693 PGY1 and PGY2 residents who participated (2258 male [61.1%]), 1775 (48.1%) reported feeling unprepared for residency. Approximately half of surgery residents took overnight call infrequently (≤2 per month) during their core medical student clerkship (1904 [51.6%]) or their subinternship (1600 [43.3%]); 524 (14.2%) took no call during their core clerkship. In multivariable analysis, residents were more likely to report feeling unprepared for residency if they were female (odds ratio [OR], 1.34; 95% CI, 1.15-1.57) or did not take call as a medical student (OR for 0 vs >4 calls, 2.72; 95% CI, 2.10-3.52). Residents who did not complete a subinternship were less likely to report feeling prepared for residency (OR, 0.68; 95% CI, 0.48-0.96). Feeling adequately prepared for residency was associated with a nearly 2-fold lower risk of experiencing burnout symptoms (OR, 0.57; 95% CI, 0.48-0.68). In interviews, the dominant themes associated with preparedness included the following: (1) various regulations limit the medical school experience, (2) overnight call facilitates preparation and selection of a specialty compatible with their preferences, and (3) adequate perceptions of residency improve expectations, resulting in improved preparedness, lower burnout rates, and lower risk of attrition.

Conclusions And Relevance: In this cross-sectional study, the perception of feeling unprepared was associated with inadequate exposure to resident responsibilities while in medical school. These findings suggest that effective preparation of medical students for residency may result in lower rates of subsequent burnout.
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http://dx.doi.org/10.1001/jamasurg.2020.2420DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7424543PMC
September 2020

COVID-19 guidance for triage of operations for thoracic malignancies: A consensus statement from Thoracic Surgery Outcomes Research Network.

J Thorac Cardiovasc Surg 2020 Aug 9;160(2):601-605. Epub 2020 Apr 9.

The extraordinary demands of managing the COVID-19 pandemic has disrupted the world's ability to care for patients with thoracic malignancies. As a hospital's COVID-19 population increases and hospital resources are depleted, the ability to provide surgical care is progressively restricted, forcing surgeons to prioritize among their cancer populations. Representatives from multiple cancer, surgical, and research organizations have come together to provide a guide for triaging patients with thoracic malignancies as the impact of COVID-19 evolves as each hospital.
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http://dx.doi.org/10.1016/j.jtcvs.2020.03.061DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7146695PMC
August 2020

Management and Long-Term Outcomes of Advanced Stage Thymoma in the United States.

Ann Thorac Surg 2021 01 11;111(1):223-230. Epub 2020 Jul 11.

Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Division of Thoracic Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois. Electronic address:

Background: Thymomas are rare tumors, with limited data regarding treatment of advanced stage disease. Although surgical resection is the mainstay of treatment, the role of additional therapy remains controversial. Our objectives were to describe treatment strategies for stage III/IV thymoma in the United States and compare survival outcomes among treatment approaches.

Methods: We identified Masaoka stage III/IV thymoma reported in the National Cancer Database between 2004 and 2016. Frequencies of treatment with surgery, chemotherapy, radiation, and combinations were calculated. Five-year overall survival was compared using the Kaplan-Meier method and log-rank test. Risk-adjusted proportional hazards modeling compared mortality between treatment regimens.

Results: A total of 1849 patients were identified (1108 stage III, 741 stage IV). Among stage III patients, 83.8% underwent resection (± other modalities) compared with 60.2% of stage IV. Surgery plus radiation was the most common regimen for stage III (32.6%), and nonsurgical treatment (definitive chemotherapy and/or radiation) was the most common for stage IV (36.4%). Overall 5-year survival was 70.3% for stage III and 58.5% for stage IV. In risk-adjusted analysis, surgery plus radiation had the lowest mortality (hazard ratio 0.41, 95% confidence interval 0.30-0.55). Patient age, tumor size, metastases, and non-academic treating hospital were associated with mortality.

Conclusions: Current treatment regimens for advanced stage thymoma vary significantly. Regimens that include surgical resection are most common and are associated with superior outcomes. Patients selected to have surgery as primary treatment had the best survival. Adjuvant radiation treatment is associated with better survival and should be considered in patients who undergo resection.
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http://dx.doi.org/10.1016/j.athoracsur.2020.05.088DOI Listing
January 2021

Adequate Lymphadenectomy as a Quality Measure in Esophageal Cancer: Is there an Association with Treatment Approach?

Ann Surg Oncol 2020 Oct 9;27(11):4443-4456. Epub 2020 Jun 9.

Department of Surgery, Surgical Outcomes and Quality Improvement Center (SOQIC), Feinberg School of Medicine, Northwestern University, 633 N St. Clair St, Chicago, IL, 60611, USA.

Background: The national comprehensive cancer network defines adequate lymphadenectomy as evaluation of ≥ 15 lymph nodes in esophageal cancer. However, varying thresholds have been suggested following neoadjuvant therapy.

Objectives: Our objectives were to (1) explore trends in adequate lymphadenectomy rates over time; (2) evaluate unadjusted lymphadenectomy yield by treatment characteristics; and (3) identify independent factors associated with adequate lymphadenectomy.

Methods: The National Cancer Data Base was used to identify patients who underwent esophagectomy for cancer from 2004 to 2015. Adequate lymphadenectomy trends over time were evaluated using the Cochrane-Armitage test, and lymph node yield by treatment approach was compared using the Mann-Whitney U and Kruskal-Wallis tests. Associations with treatment factors were assessed by multivariable logistic regression.

Results: Among 24,413 patients, 9919 (40.6%) had adequate lymphadenectomy. Meeting the nodal threshold increased over time (52.6% in 2015 vs. 26.0% in 2004; p < 0.01). Lymph node yield did not differ based on neoadjuvant therapy (median 12 [interquartile range 7-19] with and without neoadjuvant therapy; p = 0.44). Adequate lymphadenectomy was not associated with neoadjuvant therapy (40.5% vs. 40.8%, odds ratio [OR] 0.94, 95% confidence interval [CI] 0.82-1.07), but was associated with surgical approach (52.7% of laparoscopic cases, OR 1.28, 95% CI 1.06-1.56; 61.2% of robotic cases, OR 1.71, 95% CI 1.34-2.19, vs. 43.5% of open cases), and increasing annual esophagectomy volume (55.6% in the fourth quartile vs. 32.6% in the first quartile; OR 3.57, 95% CI 2.35-5.43).

Conclusions: Despite increases over time, only 50% of patients undergo adequate lymphadenectomy during esophageal cancer resection. Adequate lymphadenectomy was not associated with neoadjuvant therapy. Focusing on surgical approach and esophagectomy volume may further improve adequate lymphadenectomy rates.
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http://dx.doi.org/10.1245/s10434-020-08578-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7282211PMC
October 2020

Pre-Intubation Veno-Venous Extracorporeal Membrane Oxygenation in Patients at Risk for Respiratory Decompensation.

J Extra Corpor Technol 2020 Mar;52(1):52-57

Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois.

Veno-venous extracorporeal membrane oxygenation (VV-ECMO) has emerged as a potential life-saving treatment for patients with acute respiratory failure. Given the accumulating literature supporting the use of VV-ECMO without therapeutic levels of anticoagulation, it might be feasible to use it for planned intubation before surgical procedures. Here, we report consecutive series of patients who underwent planned initiation of VV-ECMO, without anticoagulation, before induction of general anesthesia for anticipated difficult airways or respiratory decompensation. We describe the approach to safely initiate VV-ECMO in an awake patient. We retrospectively identified patients in a prospectively maintained database who underwent planned initiation of VV-ECMO before intubation. Standard statistical methods were used to determine post-procedure outcomes. Patients included were three men and one woman, with a mean age of 34.3 ± 10.4 years. Indications included mediastinal lymphoma, foreign body obstruction, hemoptysis, and tracheo-esophageal fistula. VV-ECMO was initiated electively for all patients, and no anticoagulation was used. The median duration of VV-ECMO support was 2.5 days (1-11 days), the median length of ventilator dependence and intensive care unit stay was 1 day (1-23 days) and 5 days (4-31 days), respectively. The median length of stay was 18.5 days (8-39 days). There were no thrombotic complications and no mortality at 30 days. Initiation of awake VV-ECMO is feasible and is safe before intubation and induction of anesthesia in patients at high risk for respiratory decompensation.
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http://dx.doi.org/10.1182/JECT-1900035DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7138124PMC
March 2020

COVID-19 Guidance for Triage of Operations for Thoracic Malignancies: A Consensus Statement From Thoracic Surgery Outcomes Research Network.

Ann Thorac Surg 2020 08 9;110(2):692-696. Epub 2020 Apr 9.

The extraordinary demands of managing the COVID-19 pandemic has disrupted the world's ability to care for patients with thoracic malignancies. As a hospital's COVID-19 population increases and hospital resources are depleted, the ability to provide surgical care is progressively restricted, forcing surgeons to prioritize among their cancer populations. Representatives from multiple cancer, surgical, and research organizations have come together to provide a guide for triaging patients with thoracic malignancies as the impact of COVID-19 evolves as each hospital.
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http://dx.doi.org/10.1016/j.athoracsur.2020.03.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7146713PMC
August 2020

Feasibility of Venovenous Extracorporeal Membrane Oxygenation Without Systemic Anticoagulation.

Ann Thorac Surg 2020 10 12;110(4):1209-1215. Epub 2020 Mar 12.

Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois. Electronic address:

Background: Venovenous extracorporeal membrane oxygenation (ECMO) is increasingly being used for acute respiratory distress syndrome and as a bridge to lung transplantation. After initiation of venovenous ECMO, systemic anticoagulation therapy is traditionally administered and can cause bleeding diathesis. Here, we investigated whether venovenous ECMO can be administered without continuous systemic anticoagulation administration for patients with acute respiratory distress syndrome.

Methods: This is a retrospective review of an institutional ECMO database. We included consecutive patients from January 2015 through February 2019. Overall, 38 patients received low levels of continuous systemic anticoagulation (AC+) whereas the subsequent 36 patients received standard venous thromboprophylaxis (AC-). Published Extracorporeal Life Support Organization guidelines were used for the definition of outcomes and complications.

Results: Overall, survival was not different between the two groups (P = .58). However, patients in the AC+ group had higher rates of gastrointestinal bleeding (28.9%, vs AC- group 5.6%; P < .001). The events per patient-day of gastrointestinal bleeding was 0.00025 in the AC- group and 0.00064 in the AC+ group (P < .001). In addition, oxygenator dysfunction was increased in the AC+ group (28.9% and 0.00067 events per patient-day, vs AC- 11.1% and 0.00062 events per patient-day; P = .02). Furthermore, the AC+ group received more transfusions: packed red blood cells, AC+ group 94.7% vs AC- group 55.5% (P < .001); fresh frozen plasma, AC+ 60.5% vs AC- 16.6% (P = .001); and platelets, AC+ 84.2% vs AC- 27.7% (P < .001). There was no circuit thrombosis in either groups throughout the duration of ECMO support.

Conclusions: Our results suggest that venovenous ECMO can be safely administered without continuous systemic anticoagulation therapy. This approach may be associated with reduced bleeding diathesis and need for blood transfusions.
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http://dx.doi.org/10.1016/j.athoracsur.2020.02.011DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7486253PMC
October 2020

Survival of Primary Stereotactic Body Radiation Therapy Compared With Surgery for Operable Stage I/II Non-small Cell Lung Cancer.

Ann Thorac Surg 2020 07 5;110(1):228-234. Epub 2020 Mar 5.

Surgical Outcomes and Quality Improvement Center (SOQIC), Northwestern University Feinberg School of Medicine, Chicago, Illinois; Division of Thoracic Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois. Electronic address:

Background: Stereotactic body radiation therapy (SBRT) is an accepted primary treatment option for inoperable early-stage non-small cell lung cancer (NSCLC). The role of SBRT in the treatment of operable disease remains unclear. We retrospectively evaluated patients with operable early-stage NSCLC who elected to receive primary SBRT, examined factors associated with SBRT, and compared overall survival after surgical resection and SBRT.

Methods: The National Cancer Database was queried for patients with stage I/II, N0 NSCLC from 2004 to 2016. The proportion of patients who refused recommended surgery and were treated with SBRT was calculated. A propensity score predicting the probability of refusing surgery and receiving SBRT was generated and used to match SBRT and resected patients. Long-term overall survival was compared in the matched cohort using the Kaplan-Meier method and Cox regression.

Results: We identified 1359 patients (0.98%) who refused recommended surgery and elected SBRT. This proportion increased annually, from 0.1% in 2004 to 1.7% in 2016. Factors associated with SBRT were older age, black race, Medicaid coverage, lower T stage, and more recent diagnosis year. Propensity matching resulted in 1315 well-balanced pairs. Surgery was associated with higher median survival (74 vs 47 months, P < .01) in the matched cohort. Survival benefit persisted after adjusting for covariates on Cox regression (hazard ratio, 1.69; P < .01).

Conclusions: Median survival was significantly higher after surgery compared with SBRT in a risk-adjusted matched cohort of patients judged to be surgical candidates. Operable patients considering primary SBRT should be educated regarding this difference in survival.
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http://dx.doi.org/10.1016/j.athoracsur.2020.01.073DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7405040PMC
July 2020

Thoracoscopic lung biopsy under regional anesthesia for interstitial lung disease.

Reg Anesth Pain Med 2020 04 16;45(4):255-259. Epub 2020 Feb 16.

Department of Surgery, Division of Thoracic Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.

Background: Interstitial lung disease (ILD) management guidelines support lung biopsy-guided therapy. However, the high mortality associated with thoracoscopic lung biopsy using general anesthesia (GA) in patients with ILD has deterred physicians from offering this procedure and adopt a diagnostic approach based on high-resolution CT. Here we report that thoracoscopy under regional anesthesia could be a safer alternative for lung biopsy and effectively guide ILD treatment.

Methods: This was a single-center retrospective review of prospectively maintained database and consisted of patients who underwent thoracoscopic lung biopsy between March 2016 and March 2018. Patients were divided into two groups: (A) GA, and (B) regional anesthesia using monitored anesthesia care (MAC) and thoracic epidural anesthesia (TEA).

Results: During the study period, 44 patients underwent thoracoscopic lung biopsy. Of these, 15 underwent MAC/TEA. There were no significant differences between the two groups with regard to pulmonary function test and clinicodemographic profile. However, operative time and hospital stay were shorter in MAC/TEA group (32.5±18.5 min vs 50.8±18.4; p=0.004, 1.0±1.3 days vs 10.0±34.7 days; p<0.001, respectively). Eight patients in the GA group, but none in the MAC/TEA group, experienced worsening of ILD after lung biopsy (p=0.03). Additionally, one patient in the GA group died due to acute ILD worsening. No cases of MAC/TEA group had to be converted to GA. In all cases a pathological diagnosis could be made.

Conclusions: Thoracoscopy using regional anesthesia might be a safer alternative to lung biopsy in patients with ILD.
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http://dx.doi.org/10.1136/rapm-2019-100686DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7362779PMC
April 2020

Margin Positivity in Resectable Esophageal Cancer: Are there Modifiable Risk Factors?

Ann Surg Oncol 2020 May 13;27(5):1496-1507. Epub 2020 Jan 13.

Department of Surgery, Surgical Outcomes and Quality Improvement Center (SOQIC), Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.

Background: Patients with esophageal cancer have poor overall survival, with positive resection margins worsening survival. Margin positivity rates are used as quality measures in other malignancies, but modifiable risk factors are necessary to develop actionable targets for improvement. Our objectives were to (1) evaluate trends in esophageal cancer margin positivity, and (2) identify modifiable patient/hospital factors associated with margin positivity.

Methods: Patients who underwent esophagectomy from 2004 to 2015 were identified from the National Cancer Database. Trends in margin positivity by time and hospital volume were evaluated using Cochrane-Armitage tests. Associations between patient/hospital factors and margin positivity were assessed by multivariable logistic regression.

Results: Among 29,706 patients who underwent esophagectomy for cancer, 9.37% had positive margins. Margin positivity rates decreased over time (10.62% in 2004 to 8.61% in 2015; p < 0.001). Older patients (≥ 75 years) were more likely to have positive margins [odds ratio (OR) 2.04, 95% confidence interval (CI) 1.42-2.92], as were patients with a Charlson-Deyo Index ≥ 3 (OR 1.84, 95% CI 1.08-3.12). Patients who received neoadjuvant therapy were less likely to have positive margins (OR 0.37, 95% CI 0.29-0.47), while laparoscopic surgical approach was associated with increased margin positivity (OR 1.70, 95% CI 1.40-2.06). As the hospital annual esophagectomy volume increased, margin positivity rates decreased (7.76% in the fourth quartile vs. 11.39% in the first quartile; OR 0.70, 95% CI 0.49-0.99).

Conclusions: Use of neoadjuvant therapy, surgical approach, and hospital volume are modifiable risk factors for margin positivity in esophageal cancer. These factors should be considered in treatment planning, and margin positivity rates could be considered as a quality measure in esophageal cancer.
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http://dx.doi.org/10.1245/s10434-019-08176-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7321808PMC
May 2020

Post-Operative Complications and Readmissions Associated with Smoking Following Bariatric Surgery.

J Gastrointest Surg 2020 03 17;24(3):525-530. Epub 2019 Dec 17.

Surgical Outcomes and Quality Improvement Center (SOQIC), Feinberg School of Medicine, Northwestern University, 633 N St Clair St, 20th Floor, Chicago, IL, 60611, USA.

Background: The link between smoking and poor postoperative outcomes is well established. Despite this, current smokers are still offered bariatric surgery. We describe the risk of postoperative 30-day complications and readmission following laparoscopic sleeve gastrectomy and laparoscopic Roux-En-Y gastric bypass in smokers.

Methods: The National Surgical Quality Improvement Program database was queried to identify patients who underwent laparoscopic sleeve gastrectomy and Roux-En-Y gastric bypass from 2012 to 2017. Patient outcomes were compared based on smoking status. Primary outcomes included 30-day readmission and death or serious morbidity. Secondary outcomes included wound and respiratory complications. Multivariable logistic regression was used to determine the association between smoking status and measured outcomes.

Results: Of the 133,417 patients who underwent bariatric surgery, 12,424 (9.3%) were smokers. Smokers more frequently experienced readmission (4.9% v 4.1%, p < 0.001), death or serious morbidity (3.8% v 3.4%, p = 0.019), wound complications (2% v 1.4%, p < 0.001), and respiratory complications (0.8% v 0.5%, p < 0.001). The likelihood of death or serious morbidity (OR 1.13, 95% CI 1.01-1.26), readmission (OR 1.21, 95% CI 1.10-1.33), wound (OR 1.44, 95% CI 1.24-1.68), and respiratory complications (OR 1.69, 95% CI 1.34-2.14) were greater in smokers. The adjusted ORs remained significant on subgroup analysis of laparoscopic sleeve gastrectomy and Roux-En-Y gastric bypass patients, with the exception of death or serious morbidity in laparoscopic Roux-En-Y gastric bypass (OR 1.04, 95% CI 0.89-1.24).

Conclusions: Smokers undergoing bariatric surgery experience significantly worse 30-day outcomes when compared with non-smokers. There should be a continued emphasis on perioperative smoking cessation for patients being evaluated for bariatric surgery.
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http://dx.doi.org/10.1007/s11605-019-04488-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7485607PMC
March 2020

Utilization of Minimally Invasive Surgery and Its Association with Chemotherapy for Locally Advanced Gastric Cancer.

J Gastrointest Surg 2020 02 20;24(2):243-252. Epub 2019 Nov 20.

Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Feinberg School of Medicine, Northwestern University, 633 N St Clair Street, 20th Floor, Chicago, IL, 60611, USA.

Background: Minimally invasive surgery (MIS) is increasingly used to treat gastric cancer in the USA. A potential benefit of MIS is increased likelihood of receiving adjuvant chemotherapy. Our objectives were (1) to assess trends and predictors of MIS for gastric cancer, (2) to evaluate the association between MIS and postoperative chemotherapy, and (3) to investigate the relationship between MIS and survival.

Methods: Patients with T3 or greater and/or N+ gastric adenocarcinoma were identified from the National Cancer Database from 2010 to 2015. Patients aged ≥ 85, with metastatic disease, treated with only preoperative chemotherapy, or with contraindications to chemotherapy were excluded. Hierarchical logistic regression and Cox proportional hazards were used to assess associations between MIS and postoperative chemotherapy and survival.

Results: Of 21,872 gastric resections, 6083 (27.8%) were MIS and 15,789 (72.2%) open. The majority were partial/subtotal (68.3%). Utilization of MIS increased from 18 to 37% from 2010 to 2015 (p < 0.01). Predictors of MIS were Asian race, any insurance coverage, and treatment at high-volume centers. Among 7540 patients with locally advanced disease, MIS was associated with receiving postoperative chemotherapy compared to open surgery (77.7% vs. 71.9%; OR 1.31, 95% CI 1.11-1.54). MIS was associated with improved survival before adjusting for postoperative chemotherapy (HR 0.83; 95% CI 0.72-0.97) but not after (HR 0.87, 95% CI 0.75-1.01).

Discussion: Utilization of MIS for locally advanced gastric cancer approximately doubled during the study period. Compared to open surgery patients, MIS patients were more likely to receive postoperative chemotherapy. The increased utilization of postoperative chemotherapy may explain the associated survival advantage observed with MIS.
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http://dx.doi.org/10.1007/s11605-019-04410-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7485620PMC
February 2020

Outcomes Associated With Insertion of Indwelling Urinary Catheters by Medical Students in the Operating Room Following Implementation of a Simulation-Based Curriculum.

Acad Med 2020 03;95(3):435-441

T. Barnum is surgical nurse educator, Department of Surgical Education, Northwestern University Feinberg School of Medicine, Chicago, Illinois; ORCID: https://orcid.org/0000-0001-9709-3810. L.C. Tatebe is adjunct assistant professor of surgery, Division of Trauma and Critical Care Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, and trauma, critical care, and general surgeon, Advocate Good Samaritan Hospital, Downers Grove, Illinois; ORCID: https://orcid.org/0000-0003-0401-3813. A.L. Halverson is professor of surgery, Division of Gastrointestinal Surgery, vice chair for education, and faculty, Surgical Outcomes and Quality Improvement Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois; ORCID: https://orcid.org/0000-0003-1040-4183. I.B. Helenowski is statistician, Department of Preventative Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois. A.D. Yang is associate professor, Division of Surgical Oncology, and faculty, Surgical Outcomes and Quality Improvement Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois. D.D. Odell is associate professor, Division of Thoracic Surgery, and faculty, Surgical Outcomes and Quality Improvement Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois.

Purpose: Catheter-associated urinary tract infection (CAUTI) is a priority quality metric for hospitals. The impact of placement of indwelling urinary catheter (IUC) by medical students on CAUTI rates is not well known. This study examined the impact of a simulation-based medical student education curriculum on CAUTI rates at an academic medical center.

Method: Patient characteristics, procedural data, and outcome data from all operating room IUC insertions from June 2011 through December 2016 at the Northwestern University Feinberg School of Medicine were analyzed using a multivariable model to evaluate associations between CAUTI and inserting provider. Infection data before and after implementation of a simulation-based IUC competency course for medical students were compared.

Results: A total of 57,328 IUC insertions were recorded during the study period. Medical students inserted 12.6% (7,239) of IUCs. Medical students had the lowest overall rate of CAUTI among all providers during the study period (medical students: 0.05%, resident/fellows: 0.2%, attending physicians: 0.3%, advanced practice clinicians: 0.1%, nurses: 0.2%; P = .003). Further, medical student IUC placement was not associated with increased odds of CAUTI in multivariable analysis (odds ratio, 0.411; 95% confidence interval: 0.122, 1.382; P = .15). Implementation of a simulation-based curriculum for IUC insertion resulted in complete elimination of CAUTI in patients catheterized by medical students (0 in 3,471).

Conclusions: IUC insertion can be safely performed by medical students in the operating room. Simulation-based skills curricula for medical students can be effectively implemented and achieve clinically relevant improvements in patient outcomes.
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http://dx.doi.org/10.1097/ACM.0000000000003052DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7382914PMC
March 2020

Survival after adjuvant radiation therapy in localized small cell lung cancer treated with complete resection.

J Thorac Cardiovasc Surg 2019 12 9;158(6):1665-1677.e2. Epub 2019 Sep 9.

Surgical Outcomes and Quality Improvement Center, Department of Surgery and Center for Healthcare Studies, Feinberg School of Medicine, Northwestern University, Chicago, Ill; Northwestern Institute for Comparative Effectiveness Research in Oncology, Northwestern University, Chicago, Ill; Division of Thoracic Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Ill; Robert H. Lurie Comprehensive Cancer Center, Feinberg School of Medicine, Northwestern University, Chicago, Ill. Electronic address:

Objectives: To determine whether there is an overall survival (OS) benefit to the addition of thoracic radiation therapy (RT) following R0 resection of pathologic (p) T1 or pT2 N0 M0 small cell lung cancer.

Methods: Using the National Cancer Database, we performed a retrospective cohort analysis. Patients who underwent R0 resection for pT1 or p2 N0 M0 small cell lung cancer, stratified by receipt of adjuvant thoracic RT, were compared on the basis of OS using hierarchical Cox Proportional hazards models.

Results: Of 4969 patients diagnosed with pT1or pT2 N0 M0 SCLC from 2004 to 2014, 1617 (33%) underwent R0 resection of their primary tumor; of these resected patients, 146 (9.0%) had adjuvant thoracic RT. In unadjusted analysis, there was no significant difference in OS between groups (median survival: surgery alone, 62.2 months vs surgery+RT, 43.8 months; P = .1436). In multivariable analysis, RT was not associated with improved survival (P = .099). There was no significant difference in unadjusted or adjusted survival associated with receipt of RT in both a young and healthy cohort (P = .647 for unadjusted and P = .858 for adjusted) and a matched cohort (P = .867 and P = .954). In the matched cohort, improved OS was associated with younger patient age (adjusted hazard ratio, 1.07; 95% confidence interval, 1.04-1.10; P < .001), female sex (adjusted hazard ratio, 0.68, 95% confidence interval, 0.47-0.97; P = .035), and smaller tumors (adjusted hazard ratio, 1.02; 95% confidence interval, 1.01-1.03; P = .005). Having 2 or more comorbidities was associated with worse OS (adjusted hazard ratio, 2.16; 95% confidence interval, 1.21-3.86; P = .009).

Conclusions: Although complete resection was accomplished in a minority of patients, for these patients, survival was good. The addition of thoracic RT to complete resection does not appear to confer additional survival benefit.
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http://dx.doi.org/10.1016/j.jtcvs.2019.08.031DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7405041PMC
December 2019

Post-operative complications and readmissions following outpatient elective Nissen fundoplication.

Surg Endosc 2020 05 6;34(5):2143-2148. Epub 2019 Aug 6.

Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Feinberg School of Medicine, Northwestern University, 633 N St Clair St, 20th Floor, Chicago, IL, 60611, USA.

Introduction: Traditionally, laparoscopic Nissen fundoplication (LNF) has been considered an inpatient procedure. Advances in surgical and anesthetic techniques have led to a shift towards outpatient LNF procedures. However, differences in surgical outcomes between outpatient and inpatient LNF are poorly understood. The objectives of this study were (1) to describe the frequency of outpatient LNF in a national cohort and (2) to identify any differences in complications or readmission rates between outpatient and inpatient LNF.

Methods: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was used to identify elective LNF cases from 2012 to 2016. Patients discharged on the day of surgery were compared to those discharged 24-48 h post-operatively. Outcomes included 30-day readmission and death or serious morbidity (DSM). Bivariate analyses were completed with Chi squared testing for categorical variables and two sided t tests for continuous variables. Associations between outpatient surgery and outcomes were assessed using multivariable logistic regression. Differences in readmission were analyzed using Kaplan-Meier failure estimates and log-rank tests.

Results: Of 7734 patients who underwent elective LNF, 568 (7.3%) were discharged on the day of surgery. The overall 30-day readmission rate was 4.1% (n = 316) and the overall rate of DSM was 1.0% (n = 79). The most common 30-day readmission diagnoses overall were infectious complications (16.1%), dysphagia (12.9%), and abdominal pain (11.7%). On multivariable analysis, there was no association between outpatient surgery and 30-day readmission (3.9% vs. 4.1%; aOR 0.97, 95% CI 0.62-1.52, p = 0.908) or DSM (1.1% vs. 1.0%; aOR 0.91, 95%CI 0.36-2.29, p = 0.848). Kaplan-Meier analysis showed no difference in rates of hospital readmission between groups at 30-days from discharge (3.9% vs. 4.1%, p = 0.325).

Conclusions: Among patients undergoing elective LNF, there were no significant differences in post-operative complications and 30-day readmission when compared to traditional inpatient postoperative care. Further consideration should be given to transitioning LNF to an outpatient procedure.
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http://dx.doi.org/10.1007/s00464-019-07020-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7382912PMC
May 2020

Failure to administer recommended chemotherapy: acceptable variation or cancer care quality blind spot?

BMJ Qual Saf 2020 02 31;29(2):103-112. Epub 2019 Jul 31.

Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA

Background: Chemotherapy quality measures consider hospitals compliant when chemotherapy is recommended, even if it is not received. This may mask shortcomings in cancer care delivery. Objectives of this study were to (1) identify patient factors associated with failure to receive recommended chemotherapy without a documented contraindication and (2) assess hospital variation in failure to administer recommended chemotherapy.

Methods: Patients from 2005 to 2015 with breast, colon and lung cancers who failed to receive recommended chemotherapy were identified using the National Cancer Database. Hospital-level rates of failure to administer recommended chemotherapy were calculated, and patient and hospital factors associated with failure to receive recommended chemotherapy were identified by multivariable logistic regression.

Results: A total of 183 148 patients at 1281 hospitals were analysed. Overall, 3.5% of patients with breast, 6.6% with colon and 10.7% with lung cancers failed to receive recommended chemotherapy. Patients were less likely to receive recommended chemotherapy in all cancers if uninsured or on Medicaid (p<0.05), as were non-Hispanic black patients with both breast and colon cancer (p<0.001). Significant hospital variation was observed, with hospital-level rates of failure to administer recommended chemotherapy as high as 21.8% in breast, 40.2% in colon and 40.0% in lung cancers.

Conclusions And Relevance: Though overall rates are low, failure to receive recommended chemotherapy is associated with sociodemographic factors. Hospital variation in failure to administer recommended chemotherapy is masked by current quality measure definitions and may define a significant and unmeasured difference in hospital quality.
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http://dx.doi.org/10.1136/bmjqs-2019-009742DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7382916PMC
February 2020

Evaluation of adherence to the Commission on Cancer lung cancer quality measures.

J Thorac Cardiovasc Surg 2019 03 13;157(3):1219-1235. Epub 2018 Nov 13.

Northwestern Institute for Comparative Effectiveness Research in Oncology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Feinberg School of Medicine, Chicago, Ill; Surgical Outcomes and Quality Improvement Center, Department of Surgery, Northwestern University, Feinberg School of Medicine, Chicago, Ill; Center for Healthcare Studies, Institute for Public Health and Medicine, Northwestern University, Feinberg School of Medicine, Chicago, Ill; Division of Surgical Oncology, Department of Surgery, Northwestern University, Feinberg School of Medicine, Chicago, Ill.

Objective: In this study we present historic data on adherence to and survival outcomes associated with recently introduced quality measures for the management of non-small-cell lung cancer.

Methods: The National Cancer Data Base was queried to identify all patients with non-small-cell lung cancer from 1998 to 2011. Adherence to guidelines was assessed for each of 3 Commission on Cancer-defined quality measures: (1) sampling 10 regional lymph nodes at surgery; (2a) surgery within 120 days of neoadjuvant chemotherapy or, (2b) 180 days of adjuvant chemotherapy; and (3) nonsurgical primary therapy in cN2 disease. The likelihood of measure adherence and the association of measure adherence with all-cause mortality were analyzed controlling for patient, hospital, and time period characteristics.

Results: Regional lymph node sampling was inadequate in 72.7% of cases. Only 28.7% began adjuvant chemotherapy within 180 days of surgery. However, 96.5% of patients who received neoadjuvant chemotherapy proceeded to surgery within 120 days and surgery was first-line treatment for cN2 disease in only 3.7% of patients. Uninsured or Medicaid status was an independent risk factor for a prolonged delay between neoadjuvant chemotherapy and surgery (odds ratio, 1.36; 95% confidence interval, 1.08-1.72) and surgery and adjuvant treatment (odds ratio, 1.92; 95% confidence interval, 1.69-2.19). Overall survival was significantly better in patients whose care conformed to quality standards for nodal sampling (measure 1), and timing of chemotherapy.

Conclusions: Adherence rates for nodal sampling at the time of surgery and receipt of adjuvant chemotherapy were low. These findings highlight opportunities for improvement efforts, but more measures are needed to more broadly assess the quality of lung cancer care.
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http://dx.doi.org/10.1016/j.jtcvs.2018.09.126DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7382915PMC
March 2019

The effect of gender on operative autonomy in general surgery residents.

Surgery 2019 11 17;166(5):738-743. Epub 2019 Jul 17.

Department of Surgery, University of Michigan, Ann Arbor.

Background: Despite an increasing number of women in the field of surgery, bias regarding cognitive or technical ability may continue to affect the experience of female trainees differently than their male counterparts. This study examines the differences in the degree of operative autonomy given to female compared with male general surgery trainees.

Methods: A smartphone app was used to collect evaluations of operative autonomy measured using the 4-point Zwisch scale, which describes defined steps in the progression from novice ("show and tell") to autonomous surgeon ("supervision only"). Differences in autonomy between male and female residents were compared using hierarchical logistic regression analysis.

Results: A total of 412 residents and 524 faculty from 14 general surgery training programs evaluated 8,900 cases over a 9-month period. Female residents received less autonomy from faculty than did male residents overall (P < .001). Resident level of training and case complexity were the strongest predictors of autonomy. Even after controlling for potential confounding factors, including level of training, intrinsic procedural difficulty, patient-related case complexity, faculty sex, and training program environment, female residents still received less operative autonomy than their male counterparts. The greatest discrepancy was in the fourth year of training.

Conclusion: There is a sex-based difference in the autonomy granted to general surgery trainees. This gender gap may affect female residents' experience in training and possibly their preparation for practice. Strategies need to be developed to help faculty and residents work together to overcome this gender gap.
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http://dx.doi.org/10.1016/j.surg.2019.06.006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7382913PMC
November 2019
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