Publications by authors named "Karl Y Bilimoria"

320 Publications

Experiences of Gender Discrimination and Sexual Harassment Among Residents in General Surgery Programs Across the US.

JAMA Surg 2021 Jul 28. Epub 2021 Jul 28.

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

Importance: Mistreatment is a common experience among surgical residents and is associated with burnout. Women have been found to experience mistreatment at higher rates than men. Further characterization of surgical residents' experiences with gender discrimination and sexual harassment may inform solutions.

Objective: To describe the types, sources, and factors associated with (1) discrimination based on gender, gender identity, or sexual orientation and (2) sexual harassment experienced by residents in general surgery programs across the US.

Design, Setting, And Participants: This cross-sectional national survey study was conducted after the 2019 American Board of Surgery In-Training Examination (ABSITE). The survey asked respondents about their experiences with gender discrimination and sexual harassment during the academic year starting July 1, 2018, through the testing date in January 2019. All clinical residents enrolled in general surgery programs accredited by the Accreditation Council for Graduate Medical Education were eligible.

Exposures: Specific types, sources, and factors associated with gender-based discrimination and sexual harassment.

Main Outcomes And Measures: Primary outcome was the prevalence of gender discrimination and sexual harassment. Secondary outcomes included sources of discrimination and harassment and associated individual- and program-level factors using gender-stratified multivariable logistic regression models.

Results: The survey was administered to 8129 eligible residents; 6956 responded (85.6% response rate)from 301 general surgery programs. Of those, 6764 residents had gender data available (3968 [58.7%] were male and 2796 [41.3%] were female individuals). In total, 1878 of 2352 female residents (79.8%) vs 562 of 3288 male residents (17.1%) reported experiencing gender discrimination (P < .001), and 1026 of 2415 female residents (42.5%) vs 721 of 3360 male residents (21.5%) reported experiencing sexual harassment (P < .001). The most common type of gender discrimination was being mistaken for a nonphysician (1943 of 5640 residents [34.5%] overall; 1813 of 2352 female residents [77.1%]; 130 of 3288 male residents [4.0%]), with patients and/or families as the most frequent source. The most common form of sexual harassment was crude, demeaning, or explicit comments (1557 of 5775 residents [27.0%] overall; 901 of 2415 female residents [37.3%]; 656 of 3360 male residents [19.5%]); among female residents, the most common source of this harassment was patients and/or families, and among male residents, the most common source was coresidents and/or fellows. Among female residents, gender discrimination was associated with pregnancy (odds ratio [OR], 1.93; 95% CI, 1.03-3.62) and higher ABSITE scores (highest vs lowest quartile: OR, 1.67; 95% CI, 1.14-2.43); among male residents, gender discrimination was associated with parenthood (OR, 1.72; 95% CI, 1.31-2.27) and lower ABSITE scores (highest vs lowest quartile: OR, 0.57; 95% CI, 0.43-0.76). Senior residents were more likely to report experiencing sexual harassment than interns (postgraduate years 4 and 5 vs postgraduate year 1: OR, 1.77 [95% CI, 1.40-2.24] among female residents; 1.31 [95% CI, 1.01-1.70] among male residents).

Conclusions And Relevance: In this study, gender discrimination and sexual harassment were common experiences among surgical residents and were frequently reported by women. These phenomena warrant multifaceted context-specific strategies for improvement.
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http://dx.doi.org/10.1001/jamasurg.2021.3195DOI Listing
July 2021

Experiences of Gender Discrimination and Sexual Harassment Among Residents in General Surgery Programs Across the US.

JAMA Surg 2021 Jul 28. Epub 2021 Jul 28.

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

Importance: Mistreatment is a common experience among surgical residents and is associated with burnout. Women have been found to experience mistreatment at higher rates than men. Further characterization of surgical residents' experiences with gender discrimination and sexual harassment may inform solutions.

Objective: To describe the types, sources, and factors associated with (1) discrimination based on gender, gender identity, or sexual orientation and (2) sexual harassment experienced by residents in general surgery programs across the US.

Design, Setting, And Participants: This cross-sectional national survey study was conducted after the 2019 American Board of Surgery In-Training Examination (ABSITE). The survey asked respondents about their experiences with gender discrimination and sexual harassment during the academic year starting July 1, 2018, through the testing date in January 2019. All clinical residents enrolled in general surgery programs accredited by the Accreditation Council for Graduate Medical Education were eligible.

Exposures: Specific types, sources, and factors associated with gender-based discrimination and sexual harassment.

Main Outcomes And Measures: Primary outcome was the prevalence of gender discrimination and sexual harassment. Secondary outcomes included sources of discrimination and harassment and associated individual- and program-level factors using gender-stratified multivariable logistic regression models.

Results: The survey was administered to 8129 eligible residents; 6956 responded (85.6% response rate)from 301 general surgery programs. Of those, 6764 residents had gender data available (3968 [58.7%] were male and 2796 [41.3%] were female individuals). In total, 1878 of 2352 female residents (79.8%) vs 562 of 3288 male residents (17.1%) reported experiencing gender discrimination (P < .001), and 1026 of 2415 female residents (42.5%) vs 721 of 3360 male residents (21.5%) reported experiencing sexual harassment (P < .001). The most common type of gender discrimination was being mistaken for a nonphysician (1943 of 5640 residents [34.5%] overall; 1813 of 2352 female residents [77.1%]; 130 of 3288 male residents [4.0%]), with patients and/or families as the most frequent source. The most common form of sexual harassment was crude, demeaning, or explicit comments (1557 of 5775 residents [27.0%] overall; 901 of 2415 female residents [37.3%]; 656 of 3360 male residents [19.5%]); among female residents, the most common source of this harassment was patients and/or families, and among male residents, the most common source was coresidents and/or fellows. Among female residents, gender discrimination was associated with pregnancy (odds ratio [OR], 1.93; 95% CI, 1.03-3.62) and higher ABSITE scores (highest vs lowest quartile: OR, 1.67; 95% CI, 1.14-2.43); among male residents, gender discrimination was associated with parenthood (OR, 1.72; 95% CI, 1.31-2.27) and lower ABSITE scores (highest vs lowest quartile: OR, 0.57; 95% CI, 0.43-0.76). Senior residents were more likely to report experiencing sexual harassment than interns (postgraduate years 4 and 5 vs postgraduate year 1: OR, 1.77 [95% CI, 1.40-2.24] among female residents; 1.31 [95% CI, 1.01-1.70] among male residents).

Conclusions And Relevance: In this study, gender discrimination and sexual harassment were common experiences among surgical residents and were frequently reported by women. These phenomena warrant multifaceted context-specific strategies for improvement.
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http://dx.doi.org/10.1001/jamasurg.2021.3195DOI Listing
July 2021

Barriers to Post-Discharge Monitoring and Patient-Clinician Communication: A Qualitative Study.

J Surg Res 2021 Jul 15;268:1-8. Epub 2021 Jul 15.

Surgical Outcomes and Quality Improvement Center, Department of Surgery, Northwestern Medicine, Chicago, Illinois; Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, Illinois. Electronic address:

Introduction: As postoperative length of stay has decreased for many operations, the proportion of complications occurring post-discharge is increasing. Early identification and management of these complications requires overcoming barriers to effective post-discharge monitoring and communication. The aim of this study was to identify barriers to post-discharge monitoring and patient-clinician communication through a qualitative study of surgical patients and clinicians.

Materials And Methods: Semi-structured interviews and focus groups were held with gastrointestinal surgery patients and clinicians. Participants were asked about barriers to post-discharge monitoring and communication. Each transcript was coded by 2 of 4 researchers, and recurring themes related to communication and care barriers were identified.

Results: A total of 15 patients and 17 clinicians participated in interviews and focus groups. Four themes which encompassed barriers to post-discharge monitoring and communication were identified from patient interviews, and 4 barriers were identified from clinician interviews and focus groups. Patient-identified barriers included education and expectation setting, technology access and literacy, availability of resources and support, and misalignment of communication preferences, while clinician-identified barriers included health education, access to clinical team, healthcare practitioner time constraints, and care team experience and consistency.

Conclusions: Multiple barriers exist to effective post-discharge monitoring and patient-clinician communication among surgical patients. These barriers must be addressed to develop an effective system for post-discharge care after surgery.
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http://dx.doi.org/10.1016/j.jss.2021.06.032DOI Listing
July 2021

Quality and Safety in Surgery: Challenges and Opportunities.

Jt Comm J Qual Patient Saf 2021 May 21. Epub 2021 May 21.

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http://dx.doi.org/10.1016/j.jcjq.2021.05.003DOI Listing
May 2021

National Evaluation of Surgical Resident Grit and the Association With Wellness Outcomes.

JAMA Surg 2021 Jun 30. Epub 2021 Jun 30.

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

Importance: Grit, defined as perseverance and passion for long-term goals, is predictive of success and performance even among high-achieving individuals. Previous studies examining the effect of grit on attrition and wellness during surgical residency are limited by low response rates or single-institution analyses.

Objectives: To characterize grit among US general surgery residents and examine the association between resident grit and wellness outcomes.

Design, Setting, And Participants: A cross-sectional national survey study of 7464 clinically active general surgery residents in the US was administered in conjunction with the 2018 American Board of Surgery In-Training Examination and assessed grit, burnout, thoughts of attrition, and suicidal thoughts during the previous year. Multivariable logistic regression models were constructed to assess the association of grit with resident burnout, thoughts of attrition, and suicidal thoughts. Statistical analyses were performed from June 1 to August 15, 2019.

Exposures: Grit was measured using the 8-item Short Grit Scale (scores range from 1 [not at all gritty] to 5 [extremely gritty]).

Main Outcomes And Measures: The primary outcome was burnout. Secondary outcomes were thoughts of attrition and suicidal thoughts within the past year.

Results: Among 7464 residents (7413 [99.3%] responded; 4469 men [60.2%]) from 262 general surgery residency programs, individual grit scores ranged from 1.13 to 5.00 points (mean [SD], 3.69 [0.58] points). Mean (SD) grit scores were significantly higher in women (3.72 [0.56] points), in residents in postgraduate training year 4 or 5 (3.72 [0.58] points), and in residents who were married (3.72 [0.57] points; all P ≤ .001), although the absolute magnitude of the differences was small. In adjusted analyses, residents with higher grit scores were significantly less likely to report duty hour violations (odds ratio [OR], 0.85; 95% CI, 0.77-0.93), dissatisfaction with becoming a surgeon (OR, 0.53; 95% CI, 0.48-0.59), burnout (OR, 0.53; 95% CI, 0.49-0.58), thoughts of attrition (OR, 0.61; 95% CI, 0.55-0.67), and suicidal thoughts (OR, 0.58; 95% CI, 0.47-0.71). Grit scores were not associated with American Board of Surgery In-Training Examination performance. For individual residency programs, mean program-level grit scores ranged from 3.18 to 4.09 points (mean [SD], 3.69 [0.13] points).

Conclusions And Relevance: In this national survey evaluation, higher grit scores were associated with a lower likelihood of burnout, thoughts of attrition, and suicidal thoughts among general surgery residents. Given that surgical resident grit scores are generally high and much remains unknown about how to employ grit measurement, grit is likely not an effective screening instrument to select residents; instead, institutions should ensure an organizational culture that promotes and supports trainees across this elevated range of grit scores.
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http://dx.doi.org/10.1001/jamasurg.2021.2378DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8246335PMC
June 2021

Rapid Response Teams as a Patient Safety Practice for Failure to Rescue.

JAMA 2021 07;326(2):179-180

Department of Surgery, University of Michigan.

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http://dx.doi.org/10.1001/jama.2021.7510DOI Listing
July 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

An Evolving Hospital Quality Star Rating System From CMS: Aligning the Stars.

JAMA 2021 Jun;325(21):2151-2152

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

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http://dx.doi.org/10.1001/jama.2021.6946DOI Listing
June 2021

Burnout Phenotypes Among U.S. General Surgery Residents.

J Surg Educ 2021 Apr 29. Epub 2021 Apr 29.

Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery and Center for Health Services and Outcomes Research, Feinberg School of Medicine, Northwestern University, Chicago, Illinois; Division of Pediatric Surgery, Ann & Robert H. Lurie Children's Hospital, Feinberg School of Medicine, Northwestern University, Chicago, Illinois. Electronic address:

Objective: Although well-established metrics exist to measure workplace burnout, researchers disagree about how to categorize individuals based on assessed symptoms. Using a person-centered approach, this study identifies classes of burnout symptomatology in a large sample of general surgery residents in the United States.

Design, Setting, Participants: A survey was administered following the 2018 American Board of Surgery In-Training Examination (ABSITE) to study wellness among U.S. general surgery residents. Latent class models identified distinct classes of residents based on their responses to the emotional exhaustion and depersonalization questions of the modified abbreviated Maslach Burnout Inventory (aMBI). Classes were assigned representative names, and the characteristics of their members and residency programs were compared.

Results: The survey was completed by 7415 surgery residents from 263 residency programs nationwide (99.3% response rate). Five burnout classes were found: Burned Out (unfavorable score on all six items, 9.8% of total), Fully Engaged (favorable score on all six items, 23.1%), Fatigued (favorable on all items except frequent fatigue, 32.2%), Overextended (frequent fatigue and burnout from work, 16.7%), and Disengaged (weekly symptoms of fatigue and callousness, 18.1%). Within the more symptomatic classes (Burned Out, Overextended, and Disengaged), men manifested more depersonalization symptoms, whereas women reported more emotional exhaustion symptoms. Burned Out residents were characterized by reports of mistreatment (abuse, sexual harassment, and gender-, racial-, or pregnancy and/or childcare-based discrimination), duty hour violations, dissatisfaction with duty hour regulations or time for rest, and low ABSITE scores.

Conclusions: Burnout is multifaceted, with complex and variable presentations. Latent class modeling categorizes general surgery residents based on their burnout symptomatology. Organizations should tailor their efforts to address the unique manifestations of each class as well as shared drivers.
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http://dx.doi.org/10.1016/j.jsurg.2021.03.019DOI Listing
April 2021

Behind the Curtain-Implications of Anesthesia Volume on Outcomes.

JAMA Surg 2021 May;156(5):488

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

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http://dx.doi.org/10.1001/jamasurg.2021.0136DOI Listing
May 2021

Emergency Department Length of Stay and Mortality in Critically Injured Patients.

J Intensive Care Med 2021 Mar 1:885066621995426. Epub 2021 Mar 1.

University of California Davis, Sacramento, CA.

Objective: Multicenter data from 2 decades ago demonstrated that critically ill and injured patients spending more than 6 hours in the emergency department (ED) before transfer to the intensive care unit (ICU) had higher mortality rates. A contemporary analysis of ED length of stay in critically injured patients at American College of Surgeons' Trauma Quality Improvement Program (ACS-TQIP) centers was performed to test whether prolonged ED length of stay is still associated with mortality.

Methods: This was an observational cohort study of critically injured patients admitted directly to ICU from the ED in ACS-TQIP centers from 2010-2015. Spending more than 6 hours in the ED was defined as prolonged ED length of stay. Patients with prolonged ED length of stay were matched to those with non-prolonged ED length of stay and mortality was compared.

Main Results: A total of 113,097 patients were directly admitted from the ED to the ICU following injury. The median ED length of stay was 167 minutes. Prolonged ED length of stay occurred in 15,279 (13.5%) of patients. Women accounted for 29.4% of patients with prolonged ED length of stay but only 25.8% of patients with non-prolonged ED length of stay, < 0.0001. Mortality rates were similar after matching-4.5% among patients with prolonged ED length of stay versus 4.2% among matched controls. Multivariable logistic regression of the matched cohorts demonstrated prolonged ED length of stay was not associated with mortality. However, women had higher adjusted mortality compared to men Odds Ratio = 1.41, 95% Confidence Interval 1.28 -1.61, < 0.0001.

Conclusion: Prolonged ED length of stay is no longer associated with mortality among critically injured patients. Women are more likely to have prolonged ED length of stay and mortality.
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http://dx.doi.org/10.1177/0885066621995426DOI Listing
March 2021

Comprehensive Characterization of the General Surgery Residency Learning Environment and the Association With Resident Burnout.

Ann Surg 2021 07;274(1):6-11

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

Objectives: To characterize the learning environment (ie, workload, program efficiency, social support, organizational culture, meaning in work, and mistreatment) and evaluate associations with burnout in general surgery residents.

Background Summary Data: Burnout remains high among general surgery residents and has been linked to workplace exposures such as workload, discrimination, abuse, and harassment. Associations between other measures of the learning environment are poorly understood.

Methods: Following the 2019 American Board of Surgery In-Training Examination, a cross-sectional survey was administered to all US general surgery residents. The learning environment was characterized using an adapted Areas of Worklife survey instrument, and burnout was measured using an abbreviated Maslach Burnout Inventory. Associations between burnout and measures of the learning environment were assessed using multivariable logistic regression.

Results: Analysis included 5277 general surgery residents at 301 programs (85.6% response rate). Residents reported dissatisfaction with workload (n = 784, 14.9%), program efficiency and resources (n = 1392, 26.4%), social support and community (n = 1250, 23.7%), organizational culture and values (n = 853, 16.2%), meaning in work (n = 1253, 23.7%), and workplace mistreatment (n = 2661, 50.4%). The overall burnout rate was 43.0%, and residents were more likely to report burnout if they also identified problems with residency workload [adjusted odds ratio (aOR) 1.60, 95% confidence interval (CI) 1.31-1.94], efficiency (aOR 1.74; 95% CI 1.49-2.03), social support (aOR 1.37, 95% CI 1.15-1.64), organizational culture (aOR 1.64; 95% CI 1.39-1.93), meaning in work (aOR 1.87; 95% CI 1.56-2.25), or experienced workplace mistreatment (aOR 2.49; 95% CI 2.13-2.90). Substantial program-level variation was observed for all measures of the learning environment.

Conclusions: Resident burnout is independently associated with multiple aspects of the learning environment, including workload, social support, meaning in work, and mistreatment. Efforts to help programs identify and address weaknesses in a targeted fashion may improve trainee burnout.
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http://dx.doi.org/10.1097/SLA.0000000000004796DOI Listing
July 2021

The Role of Personal Accomplishment in General Surgery Resident Well-being.

Ann Surg 2021 07;274(1):12-17

Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois.

Objective: To investigate the association of personal accomplishment (PA) with the other subscales, assess its association with well-being outcomes, and evaluate drivers of PA by resident level.

Background: Most studies investigating physician burnout focus on the emotional exhaustion (EE) and depersonalization (DP) subscales, neglecting PA. Therefore, the role of PA is not well understood.

Methods: General surgery residents were surveyed following the 2019 American Board of Surgery In-Training Examination regarding their learning environment. Pearson correlations of PA with EE and DP were assessed. Multivariable logistic regression models assessed the association of PA with attrition, job satisfaction, and suicidality and identified factors associated with PA by PGY.

Results: Residents from 301 programs were surveyed (85.6% response rate, N = 6956). Overall, 89.4% reported high PA, which varied by PGY-level (PGY1: 91.0%, PGY2/3: 87.7%, PGY4/5: 90.2%; P = 0.02). PA was not significantly correlated with EE (r = -0.01) or DP (r = -0.08). After adjusting for EE and DP, PA was associated with attrition (OR 0.60, 95%CI 0.46-0.78) and job satisfaction (OR 3.04, 95%CI 2.45-3.76) but not suicidality (OR 0.72, 95%CI 0.48-1.09). Although the only factor significantly associated with PA for interns was resident cooperation, time in operating room and clinical autonomy were significantly associated with PA for PGY2/3. For PGY4/5s, PA was associated with time for patient care, resident cooperation, and mentorship.

Conclusion: PA is a distinct metric of resident well-being, associated with job satisfaction and attrition. Drivers of PA differ by PGY level and may be targets for intervention to promote resident wellness and engagement.
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http://dx.doi.org/10.1097/SLA.0000000000004768DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8187265PMC
July 2021

Association of State Certificate of Need Regulation With Procedural Volume, Market Share, and Outcomes Among Medicare Beneficiaries.

JAMA 2020 11;324(20):2058-2068

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

Importance: Certificate of need laws provide state-level regulation of health system expenditure. These laws are intended to limit spending and control hospital expansion in order to prevent excess capacity and improve quality of care. Several states have recently introduced legislation to modify or repeal these regulations, as encouraged by executive order 13813, issued in October 2017 by the Trump administration.

Objective: To evaluate the difference in markers of hospital activity and quality by state certificate of need status. These markers include hospital procedural volume, hospital market share, county-level procedures per 10 000 persons, and patient-level postoperative outcomes.

Design, Setting, And Participants: A cross-sectional study involving Medicare beneficiaries aged 65 years or older who underwent 1 of the following 10 procedures from January 1, 2016, through November 30, 2018: total knee or hip arthroplasty, coronary artery bypass grafting, colectomy, ventral hernia repair, lower extremity vascular bypass, lung resection, pancreatic resection, cystectomy, or esophagectomy.

Exposures: State certificate of need regulation status as determined by data from the National Conference of State Legislatures.

Main Outcomes And Measures: Outcomes of interest included hospital procedural volume; hospital market share (range, 0-1; reflecting 0%-100% of market share); county-level procedures per 10 000 persons; and patient-level postoperative 30-day mortality, surgical site infection, and readmission.

Results: A total of 1 545 952 patients (58.0% women; median age 72 years; interquartile range, 68-77 years) at 3631 hospitals underwent 1 of the 10 operations. Of these patients, 468 236 (30.3%) underwent procedures in the 15 states without certificate of need regulations and 1 077 716 (69.7%) in the 35 states with certificate of need regulations. The total number of procedures ranged between 729 855 total knee arthroplasties (47.21%) and 4558 esophagectomies (0.29%). When comparing states without vs with certificate of need regulations, there were no significant differences in overall hospital procedural volume (median hospital procedure volume, 241 vs 272 operations per hospital for 3 years; absolute difference, 31; 95% CI, -27.64 to 89.64; P = .30). There were no statistically significant differences between states without vs with certificate of need regulations for median hospital market share (median, 28% vs 52%; absolute difference, 24%; 95% CI, -5% to 55%; P = .11); procedure rates per 10 000 Medicare-eligible population (median, 239.23 vs 205.41 operations per Medicare-eligible population in 3 years; absolute difference, 33.82; 95% CI, -84.08 to 16.43; P = .19); or 30-day mortality (1.17% vs 1.33%, odds ratio [OR], 1.04; 95% CI, 0.93 to 1.16; P = .52), surgical site infection (1.24% vs 1.25%; OR, 0.93; 95% CI, 0.83 to 1.04; P = .21), or readmission rate (9.69% vs 8.40%; OR, 0.80; 95% CI, 0.57 to 1.12; P = .19).

Conclusions And Relevance: Among Medicare beneficiaries who underwent a range of surgical procedures from 2016 through 2018, there were no significant differences in markers of hospital volume or quality between states without vs with certificate of need laws. Policy makers should consider reevaluating whether the current approach to certificate of need regulation is achieving the intended objectives and whether those objectives should be updated.
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http://dx.doi.org/10.1001/jama.2020.21115DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7686860PMC
November 2020

Development of a conceptual model for understanding the learning environment and surgical resident well-being.

Am J Surg 2021 02 21;221(2):323-330. Epub 2020 Oct 21.

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. Electronic address:

Background: Surgeon burnout is linked to poor outcomes for physicians and patients. Several conceptual models exist that describe drivers of physician wellness generally. No such model exists for surgical residents specifically.

Methods: A conceptual model for surgical resident well-being was adapted from published models with input gained iteratively from an interdisciplinary team. A survey was developed to measure residents' perceptions of their program. A confirmatory factor analysis (CFA) tested the fit of our proposed model construct.

Results: The conceptual model outlines eight domains that contribute to surgical resident well-being: Efficiency and Resources, Faculty Relationships and Engagement, Meaning in Work, Resident Camaraderie, Program Culture and Values, Work-Life Integration, Workload and Job Demands, and Mistreatment. CFA demonstrated acceptable fit of the proposed 8-domain model.

Conclusion: Eight distinct domains of the learning environment influence surgical resident well-being. This conceptual model forms the basis for the SECOND Trial, a study designed to optimize the surgical training environment and promote well-being.
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http://dx.doi.org/10.1016/j.amjsurg.2020.10.026DOI Listing
February 2021

Constructing Learning Curves to Benchmark Operative Performance of General Surgery Residents Against a National Cohort of Peers.

J Surg Educ 2020 Nov - Dec;77(6):e94-e102. Epub 2020 Oct 24.

Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois; Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois; Division of Pediatric Surgery, Ann and Robert H. Lurie Children's Hospital, Chicago, Illinois. Electronic address:

Objective: No method or data exist to allow surgical trainees or their programs to contextualize their technical progress. The objective of this study was to create peer benchmarks for Cumulative Sum (CUSUM) charts based upon operative evaluations from a national cohort of general surgery residents.

Design, Setting, Participants: In 2016-2018, faculty from 26 general surgery residency programs nationwide rated 328 residents' operative performance on a case-by-case basis using a validated 5-point Likert scale. An individual case was considered a "misstep" if scoring below the national median score for that procedure in that postgraduate year (PGY). We constructed 2-sided observed-expected CUSUM charts to capture each resident's cumulative performance over time relative to the national medians. Upper (failure) and lower (positive outlier) benchmarks were established based on the PGY-specific 75th percentile and median misstep rates; consistent/repeated missteps are reflected by crossing of the upper boundary. Procedures with ≤10 observations and residents who were evaluated <10 times for each PGY were excluded.

Results: Around 8,161 evaluations on 76 procedure types were analyzed. The individual misstep rate was lowest among PGY-3s at 13.3% and highest among PGY-4s at 28.6%. No interns had curves that crossed the failure boundary. 8.7% of PGY-2s and 8.9% of PGY-3s finished the year past the failure boundary. PGY-2s had the most positive outliers, with 28.3% of them demonstrating an outlying success performance beyond the lower boundary for at least once. PGY-5s most frequently failed, with 16.7% ever crossing the upper boundary and 11.1% remaining above it at graduation.

Conclusions: CUSUM is a valid statistical approach for benchmarking individual residents' operative performance against national peers as they progress through the year in real-time. With further validation, CUSUM could be used to set progression and/or graduation standards and objectively identify residents who might benefit from remediation.
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http://dx.doi.org/10.1016/j.jsurg.2020.10.001DOI Listing
June 2021

Describing the density of high-level trauma centers in the 15 largest US cities.

Trauma Surg Acute Care Open 2020 9;5(1):e000562. Epub 2020 Oct 9.

Department of Surgery, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA.

Background: There has been a proliferation of urban high-level trauma centers. The aim of this study was to describe the density of high-level adult trauma centers in the 15 largest cities in the USA and determine whether density was correlated with urban social determinants of health and violence rates.

Methods: The largest 15 US cities by population were identified. The American College of Surgeons' (ACS) and states' department of health websites were cross-referenced for designated high-level (levels 1 and 2) trauma centers in each city. Trauma centers and associated 20 min drive radius were mapped. High-level trauma centers per square mile and per population were calculated. The distance between high-level trauma centers was calculated. Publicly reported social determinants of health and violence data were tested for correlation with trauma center density.

Results: Among the 15 largest cities, 14 cities had multiple high-level adult trauma centers. There was a median of one high-level trauma center per every 150 square kilometers with a range of one center per every 39 square kilometers in Philadelphia to one center per596 square kilometers in San Antonio. There was a median of one high-level trauma center per 285 034 people with a range of one center per 175 058 people in Columbus to one center per 870 044 people in San Francisco. The median minimum distance between high-level trauma centers in the 14 cities with multiple centers was 8 kilometers and ranged from 1 kilometer in Houston to 43 kilometers in San Antonio. Social determinants of health, specifically poverty rate and unemployment rate, were highly correlated with violence rates. However, there was no correlation between trauma center density and social determinants of health or violence rates.

Discussion: High-level trauma centers density is not correlated with social determinants of health or violence rates.

Level Of Evidence: VI.

Study Type: Economic/decision.
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http://dx.doi.org/10.1136/tsaco-2020-000562DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7549441PMC
October 2020

A postdischarge venous thromboembolism risk calculator for inflammatory bowel disease surgery.

Surgery 2021 02 17;169(2):240-247. Epub 2020 Oct 17.

Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL; Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL. Electronic address:

Background: Guidelines recommend extended chemoprophylaxis for venous thromboembolism in high-risk patients having operations for inflammatory bowel disease. Quantifying patients' risk of venous thromboembolism, however, remains challenging. We sought (1) to identify factors associated with postdischarge venous thromboembolism in patients undergoing colorectal resection for inflammatory bowel disease and (2) to develop a postdischarge venous thromboembolism risk calculator to guide prescribing of extended chemoprophylaxis.

Methods: Patients who underwent an operation for inflammatory bowel disease from 2012 to 2018 were identified from the American College of Surgeons National Surgical Quality Improvement Program for colectomy and proctectomy procedure targeted modules. Postdischarge venous thromboembolism included pulmonary embolism or deep vein thrombosis diagnosed after discharge from the index hospitalization. Multivariable logistic regression estimated the association of patient/operative factors with postdischarge venous thromboembolism. A postdischarge venous thromboembolism risk calculator was subsequently constructed.

Results: Of 18,990 patients, 199 (1.1%) developed a postdischarge venous thromboembolism within the first 30 postoperative days. Preoperative factors associated with postdischarge venous thromboembolism included body mass index (1.9% with body mass index ≥35 vs 0.8% with body mass index 18.5-24.9; odds ratio 2.34 [95% confidence interval 1.49-3.67]), steroid use (1.3% vs 0.7%; odds ratio 1.91 [95% confidence interval 1.37-2.66]), and ulcerative colitis (1.5% vs 0.8% with Crohn's disease; odds ratio 1.76 [95% confidence interval 1.32-2.34]). Minimally invasive surgery was associated with postdischarge venous thromboembolism (1.2% vs 0.9% with open; odds ratio 1.42 [95% confidence interval 1.05-1.92]), as was anastomotic leak (2.8% vs 1.0%; odds ratio 2.24 [95% confidence interval 1.31-3.83]) and ileus (2.1% vs 0.9%; odds ratio 2.60 [95% confidence interval 1.91-3.54]). The predicted probability of postdischarge venous thromboembolism ranged from 0.2% to 14.3% based on individual risk factors.

Conclusion: Preoperative, intraoperative, and postoperative factors are associated with postdischarge venous thromboembolism after an operation for inflammatory bowel disease. A postdischarge venous thromboembolism risk calculator was developed which can be used to tailor extended venous thromboembolism chemoprophylaxis by individual risk.
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http://dx.doi.org/10.1016/j.surg.2020.09.006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7856037PMC
February 2021

Association Between Missed Doses of Chemoprophylaxis and VTE Incidence in a Statewide Colectomy Cohort.

Ann Surg 2021 04;273(4):e151-e152

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

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http://dx.doi.org/10.1097/SLA.0000000000004349DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7954870PMC
April 2021

Video-Based Feedback for the Improvement of Surgical Technique: A Platform for Remote Review and Improvement of Surgical Technique.

JAMA Surg 2020 11;155(11):1078-1079

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

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http://dx.doi.org/10.1001/jamasurg.2020.3286DOI Listing
November 2020

Evaluating the Association of Multiple Burnout Definitions and Thresholds With Prevalence and Outcomes.

JAMA Surg 2020 11;155(11):1043-1049

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

Importance: Physician burnout is a serious issue, given its associations with physician attrition, mental and physical health, and self-reported medical errors. Burnout is typically measured in health care by assessing the frequency of symptoms in 2 domains, emotional exhaustion and depersonalization. However, the lack of a clinically diagnostic threshold to define burnout has led to considerable variability in reported burnout rates.

Objective: To estimate the prevalence of burnout using a range of definitions (ie, requiring symptoms in both domains or just 1) and thresholds (ie, requiring symptoms to occur weekly vs a few times per year) and examine the strength of the association of various definitions of burnout with suicidal thoughts and thoughts of attrition among general surgery residents.

Design, Setting, And Participants: A cross-sectional national survey of clinically active US general surgery residents administered in conjunction with the 2019 American Board of Surgery In-Training Examination assessed burnout symptoms, thoughts of attrition, and suicidal thoughts during the past year. Multivariable logistic regression models were used to assess the association of burnout symptoms with thoughts of attrition and suicidal thoughts. Values of R2 and C statistic were used to evaluate multivariable model performance.

Exposures: Burnout was evaluated with a 6-item, modified, abbreviated Maslach Burnout Inventory for 2 burnout domains: emotional exhaustion and depersonalization.

Main Outcomes And Measures: The primary outcome was prevalence of burnout. Secondary outcomes were thoughts of attrition and suicidal thoughts within the past year.

Results: Among 6956 residents (a 85.6% response rate; including 3968 men [57.0%] and 4041 non-Hispanic White individuals [58.1%]) from 301 surgical residency programs, 2329 (38.6%) reported at least weekly symptoms of emotional exhaustion, and 1389 (23.1%) reported at least weekly depersonalization symptoms. Using the most common definition, 2607 general surgery residents (43.2%) reported weekly burnout symptoms on either subscale. Subtle changes in the definition of burnout selected resulted in prevalence estimates varying widely from 3.2% (159 residents; most stringent: daily symptoms on both subscales) to 91.4% (5521 residents; least stringent: symptoms a few times per year on either subscale). In multivariable models, all measures of higher burnout symptoms were associated with increased thoughts of attrition (depersonalization: R2, 0.097; C statistic, 0.717; emotional exhaustion: R2, 0.137; C statistic, 0.758; both: R2, 0.138; C statistic, 0.761) and suicidal thoughts (depersonalization: R2, 0.077; C statistic, 0.718; emotional exhaustion: R2, 0.102; C statistic, 0.750; both: R2, 0.106; C statistic, 0.751) among general surgery residents (all P < .001).

Conclusions And Relevance: In a national evaluation of general surgery residents, prevalence estimates of burnout varied considerably, depending on the burnout definition selected. Frequent burnout symptoms were strongly associated with both thoughts of attrition and suicide, regardless of the threshold selected. Future research on burnout should explicitly include a clear description and rationale for the burnout definition used.
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http://dx.doi.org/10.1001/jamasurg.2020.3351DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7489413PMC
November 2020

A Comprehensive Estimation of the Costs of 30-Day Postoperative Complications Using Actual Costs from Multiple, Diverse Hospitals.

Jt Comm J Qual Patient Saf 2020 10 3;46(10):558-564. Epub 2020 Jul 3.

Background: The cost of surgical care is largely measured by charges or payments, both of which are inadequate. Actual cost data from the hospital's perspective are required to accurately quantify the financial return on investment of engaging in quality improvement. The objective of this study was to define the cost of individual, 30-day postoperative complications using robust cost data from a diverse group of hospitals.

Methods: Using clinical data derived from the American College of Surgeons National Surgical Quality Improvement Program, this retrospective study assessed postoperative complications for patients who underwent surgery at one of four hospitals in 2016. Actual direct and indirect 30-day costs were obtained, and the adjusted cost per complication was determined.

Results: From the 6,387 patients identified, the three complications associated with the highest independent adjusted cost per event were prolonged ventilation ($48,168; 95% confidence interval [CI]: $21,861-$74,476), unplanned intubation ($26,718; 95% CI: $15,374-$38,062), and renal failure ($18,528; CI: $17,076-$19,981). The three complications associated with the lowest independent adjusted cost per event were urinary tract infection (-$372; 95% CI: -$1,336-$592), superficial surgical site infection ($2,473; 95% CI: -$256-$5,201) and venous thromboembolism ($7,909; 95% CI: -$17,903-$33,721). After colectomy, the adjusted independent cost of anastomotic leak was $10,195 (95% CI: $5,941-$14,449), while the cost of postoperative ileus was $10,205 (95% CI: $6,259-$14,149).

Conclusion: The actual hospital costs of complications were estimated using cost data from four diverse hospitals. These data can be used by hospitals to estimate the financial benefit of reducing surgical complications.
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http://dx.doi.org/10.1016/j.jcjq.2020.06.011DOI Listing
October 2020

Association Between Surgeon Technical Skills and Patient Outcomes.

JAMA Surg 2020 10;155(10):960-968

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

Importance: Postoperative complications remain common after surgery, but little is known about the extent of variation in operative technical skill and whether variation is associated with patient outcomes.

Objectives: To examine the (1) variation in technical skill scores of practicing surgeons, (2) association between technical skills and patient outcomes, and (3) amount of variation in patient outcomes explained by a surgeon's technical skill.

Design, Setting, And Participants: In this quality improvement study, 17 practicing surgeons submitted a video of a laparoscopic right hemicolectomy that was then rated by at least 10 blinded peer surgeons and 2 expert raters. The association between surgeon technical skill scores and risk-adjusted outcomes was examined using data from the American College of Surgeons National Surgical Quality Improvement Program. The association between technical skill scores and outcomes was examined for colorectal procedures and noncolorectal procedures (ie, assessed on whether technical skills demonstrated during colectomy were associated with patient outcomes across other cases). In addition, the proportion of patient outcomes explained by technical skill scores was examined using robust regression techniques. The study was conducted from September 23, 2016, to February 10, 2018; data analysis was performed from November 2018 to January 2019.

Exposures: Colorectal and noncolorectal procedures.

Main Outcomes And Measures: Any complication, mortality, unplanned hospital readmission, unplanned reoperation related to principal procedure, surgical site infection, and death or serious morbidity.

Results: Of the 17 surgeons included in the study, 13 were men (76%). The participants had a range from 1 to 28 years in surgical practice (median, 11 years). Based on 10 or more reviewers per video and with a maximum quality score of 5, overall technical skill scores ranged from 2.8 to 4.6. From 2014 to 2016, study participants performed a total of 3063 procedures (1120 colectomies). Higher technical skill scores were significantly associated with lower rates of any complication (15.5% vs 20.6%, P = .03; Spearman rank-order correlation coefficient r = -0.54, P = .03), unplanned reoperation (4.7% vs 7.2%, P = .02; r = -0.60, P = .01), and a composite measure of death or serious morbidity (15.9% vs 21.4%, P = .02; r = -0.60, P = .01) following colectomy. Similar associations were found between colectomy technical skill scores and patient outcomes for all types of procedures performed by a surgeon. Overall, technical skill scores appeared to account for 25.8% of the variation in postcolectomy complication rates and 27.5% of the variation when including noncolectomy complication rates.

Conclusions And Relevance: The findings of this study suggest that there is wide variation in technical skill among practicing surgeons, accounting for more than 25% of the variation in patient outcomes. Higher colectomy technical skill scores appear to be associated with lower complication rates for colectomy and for all other procedures performed by a surgeon. Efforts to improve surgeon technical skills may result in better patient outcomes.
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http://dx.doi.org/10.1001/jamasurg.2020.3007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7439214PMC
October 2020

Formative Evaluation of a Peer Video-Based Coaching Initiative.

J Surg Res 2021 01 21;257:169-177. Epub 2020 Aug 21.

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

Background: Few opportunities exist for surgeons to receive technical skills feedback after training. Surgeons at hospitals within the Illinois Surgical Quality Improvement Collaborative were invited to participate in a peer-to-peer video-based coaching initiative focused on improving technical skills in laparoscopic right colectomy. We present a formative qualitative evaluation of a video-based coaching initiative.

Methods: Concurrent with the implementation of our video-based coaching initiative, we conducted two focus groups and 15 individual semistructured interviews with participants; all interviews were audio-recorded and transcribed. A subset of surgeons participated in a group video-review session, which was observed by qualitative researchers. Transcripts and notes were analyzed using an organizational behavior framework adapted from executive coaching.

Results: Participation in the initiative was primarily motivated by the opportunity to learn from others and improve skills. Surgeons highlighted the value of self-video and peer-video assessment not only to learn new techniques but also for self-reflection and benchmarking. Barriers to participation included logistics (e.g. using the laparoscopic recording devices, coordinating schedules for peer coaching), time commitment, and a surgical culture that assumes the intent of coaching is to address deficiencies.

Conclusions: Video-based peer-coaching provides a platform for surgeons to reflect, benchmark against peers, and receive personalized feedback; however, more work is needed to increase participation and sustain involvement over time. There is an opportunity to decrease logistical barriers and increase acceptability of coaching by integrating video-based coaching into existing surgical conferences and established continuous professional development efforts.
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http://dx.doi.org/10.1016/j.jss.2020.07.048DOI Listing
January 2021

Discrimination in US Surgical Training Programs-Reply.

JAMA Surg 2020 11;155(11):1084-1085

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

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http://dx.doi.org/10.1001/jamasurg.2020.3020DOI Listing
November 2020

A Mixed-Methods Evaluation of Clinician Education Modules on Reducing Surgical Opioid Prescribing.

J Surg Res 2021 01 17;257:1-8. Epub 2020 Aug 17.

Department of Surgery and Center for Health Services and Outcomes Research, Surgical Outcomes and Quality Improvement Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois. Electronic address:

Background: In this study, we developed online interactive clinician education modules highlighting best practices to minimize opioid prescribing at discharge after surgery. The modules were implemented as part of a multicomponent quality improvement initiative across a six-hospital health system. This article describes the development and evaluation of this educational intervention.

Materials And Methods: Clinician education modules targeting surgical prescribers, nurses, and pharmacists were developed and implemented by an interdisciplinary team. Clinicians were invited to participate in an evaluation survey after completing the modules. Survey items assessed clinicians' rating of the module and intention to change clinical practice because of the module. Quantitative and qualitative survey responses were analyzed by the study team.

Results: A total of 2119 clinicians completed the module and 1831 of these clinicians (86.4%) completed the survey. Of clinicians completing the survey, 65.6% reported that they intend to change clinical practice after completing the module. Intended changes were related to increased knowledge and awareness, provider empowerment, opioid prescribing practices, nonopioid prescribing practices, and patient education. Many clinicians who indicated they do not intend to change practice reported that their clinical practices were already in line with module recommendations. Some clinicians did not perceive the module to be relevant to their role.

Conclusions: Module completion was associated with the intention to improve clinical practice in areas related to provider empowerment, opioid prescribing, nonopioid prescribing, and patient education. Evaluation data will inform future module improvements. There is an opportunity to ensure that all clinicians, including those who are not prescribers, recognize their role in opioid stewardship.
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http://dx.doi.org/10.1016/j.jss.2020.07.009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7736366PMC
January 2021
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