41.17 Subcutaneous Cefazolin to Reduce Surgical Site Infection in a Porcine Model

Posted on January 25, 2017

G. Dubrovsky1, N. Huynh1, J. Rouch1, J. P. Koulakis2, D. P. Nicolau3, C. A. Sutherland3, S. Putterman2, J. Dunn1  2University Of California – Los Angeles,Department Of Physics And Astronomy,Los Angeles, CA, USA 3Hartford Hospital,Center For Anti-Infective Research & Development,Hartford, CT, USA 1University Of California – Los Angeles,Division Of Pediatric Surgery, Department Of Surgery, David Geffen School Of Medicine,Los Angeles, CA, USA

Introduction:
In the US, FDA-approved administration routes for cefazolin include intravenous and intramuscular. Subcutaneous administration of antibiotics is not well described in the literature, but has been used in other countries and appears to be a convenient method of drug delivery in certain cases. During surgery, we hypothesize that subcutaneous injection may provide higher local concentrations of antibiotic at the incision site and thus will lower the rate of surgical site infections (SSIs). To better understand the kinetics following subcutaneous injection, we describe the serum concentration levels of cefazolin in a porcine model as an estimate of the subcutaneous concentrations.

Methods:
Inhaled gas anesthesia was administered to Yucatan pigs. A femoral arterial catheter was placed. The pigs were administered 20mL of 25 mg/kg cefazolin subcutaneously, and serial blood samples were taken for 2 hours. Blood samples were analyzed for cefazolin concentration using chromatography. The elimination rate constant was calculated by linear regression to the semi-log plot of the terminal phase of the serum concentrations. Area under the curve was calculated using the linear trapezoidal rule until the final measured concentration. The final concentration divided by the elimination rate constant was added to this.

Results:
Maximum serum concentrations of cefazolin are achieved 44.3 minutes after the time of subcutaneous injection, and are 23.7 µg/mL (Figure 1). The elimination rate constant is .004 minutes -1 and the half-life is 173 minutes. The area under the curve is 4600 µg*min/mL and the clearance is 5.4 mL/(kg*min). The relative bioavailability of subcutaneous injection is 88%.

Conclusion:
We describe the pharmacokinetics of subcutaneous administration of cefazolin. This route shows good bioavailability, although the maximum serum concentrations achieved with subcutaneous injection are not as high as those from IV injection. The serum levels have a lower peak, but the medication remains in the blood for a longer period of time. As a result, higher doses of antibiotic can be injected locally without incurring systemic toxicity. Subcutaneous administration will therefore result in higher concentrations of antibiotic at the incision site than standard IV administration and thus may be more effective in preventing SSIs. Further studies are needed to detail the exact effect of subcutaneous antibiotic injection on SSI rates.
 

39.10 Is There an Increased Incidence of Retroperitoneal Malignancies Due to Fracking?

Posted on January 25, 2017

A. Zhong2, Y. Zhang2, J. Price1, E. Villegas1, D. Vyas1, S. Joseph1  1Texas Tech University Health Sciences Center,Department Of Surgery,Odessa, TX, USA 2Texas Tech University Health Sciences Center,School Of Medicine,Lubbock, TX, USA

Introduction:  

Retroperitoneal neoplasms are rare with an annual incidence of 2.7 cases per 1,000,000. In rural West Texas there is a large amount of environmental exposure to chemicals involved in hydraulic fracturing. We suspect that chemical exposures have increased our incidence of retroperitoneal neoplasms.

Methods:  

We did a retrospective review of all retroperitoneal neoplasms seen over the past 4 years. The total patient population of the region is 300,000 served by 3 hospitals.

We reviewed patient demographics and work history. Patients that lived further than 50 miles from the hospital or that recently moved to the area were excluded.  

Results:

The expected number of cases should be 3.24 cases/4yrs. We saw a total of 9 cases that met the inclusion criteria. This represents a 278% increase over expected.

5 patients had sarcomas, 2 had cystic neoplasms, 1 had a primary retroperitoneal neuroendocrine tumor, and 1 had a lymphangioma.

6/9 patients or their spouse worked in the oilfields.  

Conclusion:

We found a 278% increase incidence of retroperitoneal malignancies in this population. 2/3 had been exposed to chemicals involved with oil manufacturing. 1/3 had passive exposure living in this area.

We believe that the incidence of retroperitoneal malignancies is substantially higher than what we report. Many patients are referred to tertiary centers and there are other institutions providing care in the area.

We recommend extensive exposure history on any patient with a retroperitoneal neoplasm. Also, we believe a national registry be developed to track patients. Finally, improved public health monitoring for possible causes of this malignancy is imperative going forward.  

39.07 Evaluation Of Parathyroid Glands With Indocyanine Green Fluorescence Angiography After Thyroidectomy

Posted on January 25, 2017

A. Rudin1, T. McKenzie1, G. B. Thompson1, D. Farley1, M. Richards1  1Mayo Clinic,Division Of General Surgery,Rochester, MN, USA

Introduction:
Hypoparathyroidism is the most common complication after a total or near-total thyroidectomy (T-NT).  Intraoperative evaluation of parathyroid viability has been limited to visual inspection. Parathyroid function has been confirmed with postoperative lab values.  Indocyanine green fluorescence angiography (ICGA) is a new adjunct that has been used in surgical procedures to assess blood flow.  This study evaluated the utility of ICGA compared to visual inspection to predict parathyroid function, guide auto-transplantation and potentially decrease permanent hypoparathyroidism.

Methods:
This was a single center retrospective study of patients who underwent T-NT between January 2015 and June 2016.  All patients were screened for hypercalcemia and those with hyperparathyroidism were excluded. Patients who had ICGA were compared to T-NT patients without ICGA. All patients had a PTH level on postoperative day 1.  Parathyroid blood supply was scored based on ICGA as none, intermediate or normal. Visual blood supply was either viable or non-viable. Glands with no ICGA uptake were auto-transplanted. Data was analyzed to assess the frequency of auto-transplantation and incidence of hypoparathyroidism between groups. ICGA was also compared to visual inspection of the parathyroid glands.

Results:
112 patients underwent T-NT, 25 with ICGA and 87 without. Auto-transplantation was more common in the ICGA group at 36% compared to 13% in the control (p=0.015). The mean postop day 1 PTH in the ICGA group was 22 vs. 21 in the control group (p= 0.30) (normal 15-65 pg/ml). 22 out of 25 patients with intraoperative ICGA had at least one parathyroid gland with normal ICGA uptake, and 3 with intermediate update.  There was no correlation with postoperative PTH levels (p=1.0). 14 of 25 patients with intraoperative ICGA had at least two parathyroid glands with normal ICGA uptake, which correlated to postoperative PTH levels >=15 in 12 patients and PTH <15 in 2. There was no difference when compared to patients with less than 2 normal ICGA glands (n=11, p=0.08)(note: <2 normal includes patients with ICGA intermediate glands). There were 83 parathyroid glands identified in the ICGA group. Visual and ICGA assessment of normal blood flow were 66/84(78%) and 52/84(61%) respectively. There were 8 glands (9%) that would have undergone auto-transplantation based on visual inspection that had adequate blood supply on ICGA. Hypoparathyroidism was present in 32 out of 87 controls (37.5%) and 8 out of 25 (32% in the ICG group).  No cases of permanent hypoparathyroidism were identified in either group.

Conclusion:

ICGA is a novel technique that may improve the assessment of parathyroid gland blood supply compared to visual inspection.  ICGA can guide more appropriate auto-transplantation without compromising postoperative parathyroid function. At least two vascularized glands on ICGA may predict postoperative parathyroid gland function.

 

38.10 Clinical Psychomotor Skills among Left and Right Handed Medical Students.

Posted on January 25, 2017

S. A. Alnassar1, S. A. Alnassar1  1University Of British Columbia,Vancouver, British Columbia, Canada

Introduction: There is a growing perception that the left handed (LH) medical students are facing difficulties while performing the clinical tasks that involve psychomotor skill, although the evidence is very limited and diverse. The present study aimed to evaluate the clinical psychomotor skills among Right-handed (RH) and left-handed (LH) medical students.

Methods: For this study, 54 (27 left handed and 27 right handed) first year medical students were selected. They were trained for different clinical psychomotor skills including suturing, laparoscopy, intravenous cannulation and urinary catheterization under the supervision of certified instructors. All students were evaluated for psychomotor skills by different instructors. The comparative performance of the students was measured by using a global rating scale, each selected criteria was allotted 5-points score with the total score of 25.

Results:There were no significant differences in the performance of psychomotor skills among LH and RH medical students. The global rating score obtained by medical students in suturing techniques was: LH 15.89±2.88, RH 16.15±2.75 (p=0.737), cannulation techniques LH 20.44±2.81, RH 20.70±2.56 (p=0.725), urinary catheterization LH 4.33±0.96 RH 4.11±1.05 (p=0.421). For laparoscopic skills total peg transfer time was shorter among LH medical students compared to RH medical students (LH 129.85±80.87 sec vs RH 135.52±104.81 sec) (p=0.825).  

Conclusion:
Among LH and RH medical students no significant difference was observed in performing the common surgical psychomotor skills. Surgical skills for LH or RH might not be a result of innate dexterity but rather the academic environment in which they are trained and assessed.  
 

38.09 Learning Curve Model Selection of FLS Transfer Task Using The Akaike Information Criterion

Posted on January 25, 2017

A. Toloff1, S. Bradley1, D. Bouwman1, D. A. Edelman1  1Wayne State University,Department Of Surgery,Detroit, MI, USA

Introduction:  Learning curves (LCs) are powerful tools.  Selection of an appropriate model allows determination of parameters useful for management of training.  LCs are used commonly in educational research but rarely in clinical teaching due to their dependence on high quality assessment at frequent intervals.  With the availability of video-assessment of all practice events of the FLS transfer task, we hypothesized that a best model could be selected from a list (linear,exponential, logarithmic,and power) using Akaike information criteria (AIC). 

Methods:  All practice events occurring in our FLS training curriculum are video logged. We scored performance on all practice events for all novice trainees from July 2015 through June 2016 who completed at least 30 trials of the FLS transfer task (49 trainees). Task completion time [TCT]) was the performance measure (it decreases with acquisition of skill). Each TCT was linked to a chronologically sequenced trial number (TN). The group average TCTs plotted by TN were fitted 4 times to commonly proposed  learning curve functions (linear, exponential, logarithmic, and power) using least squares (LS) estimation. The AIC for each model was compared.  A lower AIC means more information is preserved and identifies a superior model. Individual trainee curves were also generated for each model with a frequency count of the model providing best fit. Group TCTs at TN1 were calculated for each model and compared.  Individual estimated TCTs at TN1 were computed and compared using post-hoc testing after ANOVA.

Results: The grouped data is represented best by the power function which displays the lowest AIC.  Fitting individual data, the power function provides the best fit for 30 (61%) individuals.  The power function provides the best estimate of the TCT at TN1 for the group data.  For individuals, the power function estimate of TCT at TN1 is significantly different from the linear and exponential estimates.  

Conclusion: For the group of novice learners, skill acquisition for the FLS transfer task was fit better by the power function than linear, logarithmic, or exponential curves. The skill acquisition data for the majority of individual trainees was also fit best by the power function.  The learning curves based on the power linking function are superior to the three other candidate models we assessed and form the basis for analysis of both group and individual data.  

 

38.07 Effects of a Novel Mental Skills Curriculum on Surgical Trainees’ Attention

Posted on January 25, 2017

N. Mulji1, N. Anton1,3, L. Howley1, A. Yurco1, D. Tobben1, E. Bean2, D. Stefanidis1,3  1Carolinas Medical Center,Carolinas Simulation Center,Charlotte, NC, USA 2Get A Strong Mind,San Diego, CA, USA 3Indiana University,Department Of Surgery,Indianapolis, IN, USA

Introduction:
Appropriate management of attentional resources is important for surgeons to maintain focus to prevent compromising patient safety. This is particularly true for surgical trainees, as they may be susceptible to experience cognitive overload due to their inexperience, which can negatively impact their ability to maintain and shift focus effectively. Mental skills curricula incorporate cognitive training techniques (including thought and attention management) to help optimize performance even under challenging conditions. The objective was to assess the efficacy of a novel mental skills curriculum in improving attention management of novice surgical trainees. 

Methods:
Volunteer participants (n=60) with no previous exposure to surgery were stratified according to their baseline performance on the Fundamentals of Laparoscopic Surgery (FLS) simulator and randomized to receive mental skills training or no such training during nine proficiency-based laparoscopic training sessions. To assess attentional resources, a previously validated secondary ball and tunnel task that requires participants to distinguish between correct and incorrect patterns superimposed over the laparoscopic display, was used at each training session. To assess training effectiveness, FLS scores and secondary task scores were compared between groups using Wilcoxon Rank Sum test and within groups using Wilcoxon Signed Rank test, before and after training. To assess predictive value of improvement, the d2 Test of Attention and TOPS assessment were administered before baseline and post-test.

Results:
Fifty-five participants completed the study protocol. There were no differences in demographics, FLS performance and secondary task scores between groups at baseline. Both groups demonstrated significant improvements in primary (p<0.001) and secondary task performance (p<0.01) from baseline to post-test. While no significant differences were found between groups in primary and secondary task performance at baseline and post test, only the mental skills training group demonstrated significant improvements in correct secondary task hit rates (i.e., correctly identifying incorrect patterns) at post test compared with baseline (28% vs. 18%, respectively; p<0.05) and displayed a trend towards reduced average response times. The d2 Test of Attention and TOPS assessment did not show significant difference between or within groups at the designated time periods.

Conclusion:
The novel mental skills curriculum used in this study led to improved performance on a visual-spatial secondary task after training completion. Further evaluation of the impact of this curriculum on attentional capacity and how it can be maximized is warranted and is currently underway with more advanced learners (i.e., surgical trainees).  
 

38.05 How Does Surgical Performance Change in the Laboratory Years?

Posted on January 25, 2017

J. N. Nathwani1, K. E. Law2, B. J. Wise1, S. Lian1, M. E. Garren1, S. M. DiMarco1, C. M. Pugh1,2  1University Of Wisconsin,Surgery,Madison, WI, USA 2University Of Wisconsin,Industrial And Systems Engineering,Madison, WI, USA

Introduction: Nearly one-third of surgical residents will enter into academic development during their surgical residency, by dedicating time to a research fellowship for one to three years. Multiple motivations exist for going into academic development; including interest in an academic surgical career, requirements by surgical training programs, or taking time away from clinical years. Major interest lies in understanding how laboratory residents’ surgical skills are affected by minimal clinical exposure during academic development. A widely held concern is that the time away from clinical exposure results in surgical skills decay. This study examines the impact of the academic development years on residents’ operative performance. We hypothesize that performance will improve as laboratory residents progress through their academic years.

Methods: Surgical performance data were collected from laboratory residents (post graduate years [PGY] 2-5) in Midwest general surgery training programs during the summers of 2014 and 2015. Residents had 15 minutes to complete two steps of a simulated laparoscopic ventral hernia (LVH) repair procedure. Hernia skins from all participants were scored using a previously validated checklist. An analysis of variance (ANOVA) test compared the mean performance scores of repeat participants and one time participants.

Results:A total of 76 laboratory residents (49% female) participated. All participants completed the simulated LVH in the allotted time.  Fifteen of the 76 participants performed this procedure in both 2014 and 2015, while 61 participants performed the procedure once. The first time performance for all participants on the LVH simulator was a mean of 13.9 points (SD=5.3) out of a maximum 24 points for repair quality and completion. One time participants scored a mean of 13.4 points (SD=5.2). Repeat participants in their second performance scored a mean of 17.1 points (SD=5.9). ANOVA analysis demonstrates a statistical difference between one time performers and repeat participants in their second year (F(2, 88)=4.2, p=.016).

Conclusion:Comparing repaired hernia skins of one time participants and repeat participants shows improvement in performance while in laboratory years. Higher scores for repeat participants suggests that laboratory residents continue to improve their surgical skills despite time away from clinical exposure. This improvement in performance could be explained by personal efforts, program-specific call duties, acquisition of moonlighting opportunities, or artifact of repeated exposure to a simplified surgical task.

 

38.04 Pluralistic Ignorance And Risk Of Attrition Among Residents.

Posted on January 25, 2017

R. Panni1, M. Laurel2, K. Nandagopal3, G. Cohen3, G. M. Walton3, A. Salles1  1Washington University,Surgery,St. Louis, MO, USA 2Washington University School Of Medicine,St. Louis, MO, USA 3Stanford University,Palo Alto, CA, USA

Introduction: Attrition continues to be a major problem in general surgery residencies with an estimated one out of five residents failing to complete training. While there are a number of reasons for this, here we examine one factor, pluralistic ignorance, and its relationship to risk of attrition among surgical residents. The difference between the perception of one's own experience compared to the experiences of those around them is termed pluralistic ignorance. For example, in academic contexts, it is common for people to think that those around them are faring better, whether that be with more success, better grades, or more happiness. This feeling is often more pronounced at times of transition. In this study, we hypothesized that those who experience greater degrees of pluralistic ignorance may be at greater risk for attrition.

Methods:  Junior residents in a single general surgery residency program were surveyed on a voluntary basis for two consecutive years (2011-2012 and 2012-2013). As part of a larger study, residents were administered a questionnaire which included measures of pluralistic ignorance with items such as the number of time per week they made any mistakes, felt down, felt bothered by blaming themselves for things, were satisfied with their performance. The participants were then asked the same questions about a typical resident in their program. We measured risk of attrition with two items, how frequently they thought about leaving residency and how likely they think it is that they will complete their current residency. We examined the correlations among these measures to see whether pluralistic ignorance was related to risk of attrition.

Results:

36 residents participated in the survey (43% response rate). We found that higher degrees of pluralistic ignorance were associated with more frequent thoughts of leaving residency (rs = 0.55, p=0.0006). The less pluralistic ignorance residents experienced, the more likely they were to intend to complete their residency (rs = -0.62, p<0.0001). Thus, pluralistic ignorance was significantly associated with these two measures of risk of attrition. In regression analyses controlling for gender and post-graduate year, pluralistic ignorance was significantly predictive of the frequency of thoughts of leaving residency (B=0.75, t=3.35, p=0.002) and intention to complete residency (B=-0.76, t=-3.25, p=0.003).

 

Conclusion:
To our knowledge, pluralistic ignorance has not been examined in the context of surgical residencies. Our data suggest that this may be a predictor of risk of attrition. Perhaps more importantly, pluralistic ignorance is modifiable. At the institution where this study was performed, each post graduate year group routinely meets with a psychologist. Residents thus have an opportunity to discuss their various struggles together and realize that others are having similar experiences. Interventions such as this may reduce pluralistic ignorance and potentially decrease the risk of attrition.

37.10 Surgeon Educators and Variation in Teaching Assessments—Does Gender Bias Exist?

Posted on January 25, 2017

M. Barrett1, C. P. Magas1, N. Matusko1, R. M. Reddy1, G. Sandhu1  1University Of Michigan,General Surgery,Ann Arbor, MI, USA

Introduction: The demographics of the surgical trainee and medical student populations has seen a significant shift with women now making up 20% of US surgical residents and student populations achieving parity. Expectantly, the proportion of women surgical faculty has increased overtime, although it remains low at 10-20%. How this shift affects surgical education and the learner experience has yet to be fully elucidated. Prior work has shown that students value different attributes in surgical faculty (more nurturing) than do residents (more technical training).  We sought to assess for differences in teaching evaluations based on faculty gender, hypothesizing that students would favor teaching attributes of female faculty.

Methods: Student and resident teaching evaluations of 43 faculty (12 females, 31 males) were reviewed. Faculty rankings (1 to 43) for both students and residents were created using mean faculty educator scores over 3 years. Outlier faculty were defined by a greater than 30% deviation in ranking between residents and students. Thematic assessment was utilized for the written evaluation of these outlier faculty to better understand the teaching qualities valued by students versus residents.

Results: On analysis of all faculty (n=43), women were ranked lower overall by students (mean female rank=28th, mean male rank=19th) and residents (mean female rank=26th, mean male rank=20th). The rankings of 14 outlier educators (6 women, 8 men) were incongruent when comparing residents and students (Figure 1). The greatest ranking drop from students to residents was a male (2nd to 41st), whereas the greatest gain from students to residents was a female (41st to 8th). Thematic analysis revealed students value inclusivity and approachability and demerit intimidation and isolation whereas residents appreciate autonomy and intraoperative calmness and disvalue indecisiveness.

Conclusions:  Conventional gender biases suggest women are more nurturing and inclusive, yet emotional and indecisive whereas men are more calm and objective, yet detached and intimidating. Such biases would suggest, based on our thematic analysis, that students would value educational qualities of women whereas residents’ teaching preferences are aligned with those of males. Interestingly, despite variation in rankings between medical students and residents, both groups ranked women lower. It is unclear why students and residents assess women as less effective teachers but perhaps an unconscious bias exists. Further work is needed to understand these disparities and why they persist. This will allow for educational improvements for students, residents, and faculty educators of all genders.

37.09 Burnout is Associated with Emotional Intelligence in Surgical Residents

Posted on January 25, 2017

K. D. Cofer2, A. Gullick4, R. Hollis3, M. Morris1,3,5, J. Porterfield1,3, D. Chu1,3  1University Of Alabama At Birmingham,Gastrointestinal Surgery,Birmingham, AL, USA 2University Of Alabama At Birmingham,School Of Medicine,Birmingham, AL, USA 3University Of Alabama At Birmingham,General Surgery,Birmingham, AL, USA 4University Of Alabama At Birmingham,General Surgery Research,Birmingham, AL, USA 5Birmingham VA Medical Center,General Surgery,Birmingham, AL, USA

Introduction:   Burnout has been associated with decreased job performance in non-surgical professions and may be partly influenced by emotional intelligence (EI).  Evaluation of surgical residents currently consists of standardized tests, evaluations by faculty and peers, and clinical milestone assessment. We evaluated whether burnout was associated with emotional intelligence and job performance in surgical residents.

Methods: General surgery residents at a single institution were surveyed using the Maslach Burnout Inventory (MBI) and trait EI questionnaire (TEIQ-SF). Burnout was defined as scoring above pre-defined levels in at least two of the three measured components of burnout; exhaustion, depersonalization, and personal accomplishment. Job performance was evaluated using faculty evaluations of clinical competency-based surgical milestones and standardized test scores including the American Board of Surgery In-Training Exam (ABSITE) and the United States Medical Licensing Examination (USMLE). Statistical comparison was made using Pearson correlation and simple linear regression adjusting for PGY level.

Results: Forty residents participated in the survey (response rate 77%). Ten residents, evenly distributed from PGY 1 to PGY 5, were found to have burnout (25%). Burnout was associated with global EI (p=0.02). Of the facets of EI, burnout was significantly associated with self-control (p<0.01). Each component of burnout was associated with global EI, with the strongest correlation being with personal accomplishment (r=0.64; p<0.01). Burnout was not associated with USMLE Step 1 (p=0.12), Step 2 (p=0.56), Step 3 (p=0.97), or ABSITE percentile (p=0.33) scores. Personal accomplishment was associated with ABSITE percentile scores (r=0.35; p=0.049). None of the sixteen surgical milestone scores were significantly associated with burnout. 

Conclusion: Burnout was associated with emotional intelligence. There was no association of burnout with USMLE scores, ABSITE percentile or surgical milestones. Traditional methods of assessing resident performance may not be capturing these factors, which are critical for ensuring successful careers. Residency programs should adopt programs targeted towards improving resident emotional intelligence.

 

37.07 Resident Post Graduate Year Doesn't Influence Rate of Complications Following Inguinal Herniorrhaphy

Posted on January 25, 2017

O. Renteria1,2, A. A. Mokdad1, J. Imran1, S. Huerta1,2  1University Of Texas Southwestern Medical Center,Surgery,Dallas, TX, USA 2VA North Texas Health Care System,General Surgery,Dallas, TX, USA

Introduction:
Previous studies have demonstrated that the postgraduate year (PGY) resident level does not influence outcomes for complex vaginal surgery, carotid endarterectomy, pancreatic surgery and upper gastro-intestinal surgery.  For inguinal hernias (IH), data indicate that PGY-3 residents have lower rate of recurrence compared with PGY-1 and 2 after the repair of an open inguinal herniorrhaphy.  Lower PGY level was also associated with increased operative time for both open and laparoscopic hernia repair.   We hypothesize that when controlling for surgeon, technique, and hernia type, the outcomes for inguinal herniorrhaphy are the same independent of PGY level.  

Methods:
This is a retrospective review of only unilateral IH performed by the same surgeon between 2005-2015 at the VA North Texas Health Care System. Bilateral, recurrent IH, laparoscopic IH, femoral and IH repair simultaneously with an umbilical hernia were excluded from the analysis (n=170). Patient demographic and clinical information, perioperative data, and resident level involvement were compared between patients that had a postoperative morbidity and those that did not. Wilcoxon rank-sum test and Fisher’s exact test were used to compare the continuous and categorical outcomes, respectively. Patient postoperative morbidity was explored in a multivariable logistic regression model. The model was constructed using a forward stepwise technique. Operative time was also examined using an ordinary least square linear regression model. 

Results:
752 unilateral inguinal hernias were included in this study with the following characteristics: age (60.6±12.7 years-old), BMI (27.0±10.8 Kg/m2 ), (ASA III-IV = 51%)  Nyhus classification (type 2: 44.7%, 3a 41.6%, 3b 12.6%, 3c 1.1%.). 17.2 % of the residents involved in the repairs were PGY-1, 71.1% PGY-2-3 and 11.7% PGY4-5. The overall complication rate was 7.8% and recurrence rate was 1.2% for this cohort.  Postoperative complications for intern, junior, and senior residents, were 4%, 9%, and 6%, respectively (p=0.14).  Compared to interns, junior residents (PGY level 2-3) finished the operation 3.9 minutes faster (95% CI = -7.5 to -0.3), but there was no difference between interns and senior residents completing the operations after controlling for Nyhus hernia type.  Logistic regression did not identify PGY-level as an independent predictor of complications.  

Conclusion:
Overall, there was a slight decrease in operative time when the repair was done with junior level residents however PGY level does not influence outcomes for open, unilateral inguinal herniorrhaphy. 
 

37.05 Does the ACGME Resident Case Log Really Reflect Resident Operative Experience?

Posted on January 25, 2017

J. A. Perone1, H. B. Mehta1, J. McClintic1, R. Norcini1, P. Rothenberg1, J. Rhodes1, D. S. Tyler1, K. M. Brown1  1University Of Texas Medical Branch,Galveston, TX, USA

Introduction:

Graduates of general surgery residency programs are not consistently ready for the autonomy expected by fellowships and practice partners. In an attempt to better meet training needs, the Accreditation Council for Graduate Medical Education (ACGME) recently increased the number of cases required for resident graduation to 850, keeping the requirements for involvement in peri-operative care as part of “surgeon” role. However there is no clear evidence that increasing case numbers will improve competency or if the ACGME case log reflects the residents’ true operative experience or skill. To evaluate how accurately resident case logs reflect faculty and resident assessments of operative participation, we compared the residents’ ACGME case logs with faculty and resident surveys completed immediately following those cases.

 

Methods:

A 16-question survey was administered to residents and faculty following each case over a 4-week period.  Residents and faculty were asked to assess the resident’s role in the case, whether the resident performed the critical portions of the case, and the resident’s role in pre- and post-operative care. The survey reported data were then compared to the residents’ ACGME case logs.

 

Results:

ACGME case logs were accessible and complete for 105 cases. Eighty-three of those cases had corresponding completed faculty surveys and 95 had resident surveys. Faculty assessment of role differed from case log in 30/83 (36%) cases, with residents logging themselves as surgeon when faculty considered them first assistant in 26 of those cases.  Faculty and residents were more likely to disagree on the residents’ role in advanced cases compared to core cases, using Surgical Council on Resident Education (SCORE) definitions. (p=0.01).  Agreement was not associated with PGY year, the presence of more than one resident in the case, or any specific resident or faculty. Case logs agreed with resident self-assessment of role in 82/95 (86%) cases. In 11% of cases, residents logged their experience as surgeon despite stating in the survey that they acted as first assistant. Of the 88 cases logged as either surgeon chief or surgeon junior, residents reported meeting criteria for “surgeon” as defined by ACGME in only 55%.

Conclusion:

Resident operative experience as assessed by faculty participating in their cases is not accurately captured by the current case log system. This problem appears to be multi-factorial – residents overestimate their participation, especially in complex procedures, and residents log themselves as surgeon despite reporting that they did not fulfill criteria for that role. This suggests that the accuracy of the resident case log may be improved by logging cases in real time and involving faculty input.

37.04 Reliability and Validity of a Standardized Interviewing Instrument in Selecting Surgery Residents

Posted on January 25, 2017

J. WEBER1, S. SHEBRAIN1, A. WOODWYK1, G. MUNENE1  1WESTERN MICHIGAN HOMER STRYKER SCHOOL OF MEDICINE,GENERAL SURGERY,KALAMAZOO, MICHIGAN, USA

Introduction:
The interviewing of applicants for surgery residency is considered an important determinant of which and how applicants get ranked. The objective of this study is to evaluate the reliability and validity of a standardized interviewing assessment instrument

Methods:
A prospective analysis of interviewees using a standardized assessment instrument at a university affiliated general surgery program. Applicants were evaluated using a standardized scoring instrument.  (6 GS faculty, including the program director, and 3 GS residents), evaluated applicants on 6 characteristics (subjective and objective) using a 5-point Likert scale and a total score. Applicants were ranked at the conclusion of their interviews

Results:
There were a total of 432 assessments representing 51 applicants. The inter rater reliability (IRR) was good in all six domains (Cronbach’s alpha coefficient > 0.7). The IRR of the interviewees rank was good for the faculty, residents and the entire group (Cronbach’s alpha coefficient  >0.7). The spearman correlation between the total score and the final rank was -0.296, -0.366 and -0.294 respectively for faculty, residents and the entire group.

Conclusion:
Despite good IRR in several domains evaluated by the standardized interview instrument the total score had a low correlation with the final rank. IRR of the applicants rank was excellent despite the low correlation with the total score suggesting shared biases play a significant role in the ranking process. Adoption of best practices in the interviewing process may eliminate some of these biases 

37.03 Dedicated Research Time During Surgical Training Predicts Successful Future Research Funding

Posted on January 25, 2017

J. P. Meizoso1,2, J. J. Ray1,2, C. A. Karcutskie1,2, D. B. Horkan1,2, N. Merchant1, D. Sleeman1, N. Namias1, O. C. Velazquez1, A. S. Livingstone1, C. I. Schulman1  1University Of Miami,DeWitt Daughtry Family Department Of Surgery,Miami, FL, USA 2Jackson Memorial Hospital,Miami, FL, USA

Introduction: Dr. Francis Moore described the surgeon-scientist as a “bridge tender, channeling knowledge from biological science to the patient’s bedside and back again.” Dedicating 1+ years of research training during residency is unique to general surgery; however, prior studies conflict regarding the effect of research fellowships (RF) on future academic productivity. We hypothesize that participating in a RF during training is associated with successful future research funding.

Methods: National cross-sectional survey distributed via ACS NewsScope, ACS Communities, and social media from 11/2015–12/2015. Ninety-one subjects (47%) of 195 respondents were faculty and made up the study sample; the remainder were residents and were ineligible for the present study. Results were considered statistically significant at p≤0.05.

Results: Most subjects were male (79%) and trained at an academic program (84%). Of the entire cohort, 54 subjects (59%) completed a RF during training and 58 (64%) successfully attained research funding as faculty.  50% completed 2 years of research, 35% completed 1 year, 11% completed 3 years, and 4% completed 4+ years.  RF was associated with training in an academic program (93% vs. 70%, p=0.033); more overall publications (<0.0001), 1st author publications (p=0.001), and presentations (p=0.002) during residency; pursuing funding during training (54% vs. 5%, p<0.0001); and funding success after training compared with to those without a RF (78% vs. 43%, p=0.001) (Table).  After controlling for these differences, completing a RF was an independent predictor of post-training funding success (OR 4.04, 95% CI 1.12-14.55, p=0.033).

Conclusion: Dedicated research time during surgical training is associated with future academic productivity and funding success after training independent of number of publications, first author publications, presentations, and pursuit of funding during training.

 

37.02 Relationships Between Burnout and Study Habits on General Surgery Resident Performance on the ABSITE

Posted on January 25, 2017

M. R. Smeds1, C. R. Thrush1, F. McDaniel1, R. Gill1, M. K. Kimbrough1, B. D. Shames2, J. J. Sussman3, J. M. Galante4, C. M. Wittgen5, P. Ansari6, S. R. Allen7, M. S. Nussbaum8, D. Hess9, F. R. Bentley1  1University Of Arkansas For Medical Sciences,Department Of Surgery,Little Rock, AR, USA 2University Of Connecticut School Of Medicine,Department Of Surgery,Farmington, CT, USA 3University Of Cincinnati,Department Of Surgery,Cincinnati, OH, USA 4University Of California – Davis Medical Center,Department Of Surgery,Sacramento, CA, USA 5Saint Louis University School Of Medicine,Department Of Surgery,St. Louis, MO, USA 6Hofstra-Northwell Lenox Hill Hospital,Department Of Surgery,New York, NY, USA 7Penn State Hershey Medical Center,Department Of Surgery,Hershey, PA, USA 8University Of Florida College Of Medicine – Jacksonville,Department Of Surgery,Jacksonville, FL, USA 9Boston University,Department Of Surgery,Boston, MA, USA

Objectives:  The American Board of Surgery In-Training Examination (ABSITE) is used by programs to evaluate knowledge and readiness of trainees to sit for the general surgery certifying examination. It is often used as a tool to promote residents and may be used by fellowship programs to evaluate candidates. Burnout has been associated with job performance and satisfaction; however its presence and effects on surgical trainee’s performance is not well studied. We sought to understand factors, including burnout and study habits, that may contribute to performance on the ABSITE examination. 

Methods:   Anonymous electronic surveys were distributed to all residents at nine surgical residency programs (n=307). Questions included demographics, study habits, career interests, residency characteristics, and burnout scores using the Oldenburg Burnout Inventory, which assesses burnout due to both exhaustion (B-E) and disengagement (B-D). These surveys were then linked to individual 2016 ABSITE and USMLE step I and II scores provided by the programs in order to determine factors associated with successful ABSITE performance. 

Results:  47% (n=143) of the residents completed the survey. Of those completing the survey, 37 (26%) scored in the highest ABSITE quartile (>75th percentile) and 106 (74%) scored less than the 75th percentile. Those in the highest ABSITE quartile had significantly higher USMLE step I and step II scores (p<.01), had a regular reading schedule for the ABSITE (p<.05), more disciplined study habits (p<.01) and were more likely to use active rather than passive study strategies (p<.05). Overall, sources most commonly used were ABSITE review books and other sources of practice questions (90% and 61% respectively). Increased studying (“cramming”) prior to the examination was not associated with higher ABSITE scores. Residents on the whole showed a moderate level of burnout, particularly in the exhaustion domains, and those in the highest ABSITE quartile had significantly lower mean burnout scores on both B-D and B-E scales (p<.05).  Residents who were on a research year and those planning to go into an academic surgery careers had significantly higher ABSITE scores (p<.01), whereas those who attended a non-U.S. medical school had significantly lower ABSITE scores (p<.01). Other individual characteristics and program characteristics were unrelated to ABSITE performance (age, gender, having children, advanced degree, reported study barriers, protected study time, PGY level, duty hour violations, previously completed a research year). 

Conclusions:  Residents who perform higher on the ABSITE have a regular study schedule throughout the year, are more disciplined in their study habits using active versus passive study strategies, and report less burnout due to exhaustion or disengagement from work. Further study is needed to determine the effects of burnout on clinical duties, career advancement and satisfaction.

36.08 Patients with Dementia and Acute Surgical Abdomen: Opportunities for Palliative Care

Posted on January 25, 2017

F. J. Hwang2, S. Pentakota2, R. Singh2, A. Berlin2, A. Mosenthal2  2Rutgers New Jersey Medical School,Surgery,Newark, NJ, USA 1University Of Medicine And Dentistry Of New Jersey,General Surgery,Newark, NJ, USA

Introduction:  Patients with dementia who develop acute abdominal emergencies have high risk of morbidity and mortality. Accurate prognostication about outcomes would be helpful in order to make improved patient-centered decisions. Little is known on palliative care (PC) utilization in patients with dementia in need of emergency abdominal surgery. The purpose of this study is to characterize outcomes and factors associated with PC utilization for patients with dementia presenting with acute abdominal emergencies.

Methods:  The National Inpatient Sample database between the years of 2009 and 2013 was queried using ICD-9 codes for patients > 50 years with dementia and acute abdomen (bowel ischemia, obstruction, or perforation). Study variables were patient demographics and hospital information. Outcomes included in-hospital mortality, discharge disposition, length of stay, total charges, and receipt of palliative care. Multivariable logistic regression analysis was used to identify factors associated with receiving PC.

Results: 6,867 patients met the inclusion criteria. Among these patients, 22% (N=1530) underwent surgery; 16% (N=1090) died in hospital; 49% (N=3360) were discharged to a facility; and 10% (N=717) received palliative care. 29% (N=314) of those who died in hospital received PC. PC utilization increased over the study time period (7% in 2009 to 12% in 2013). Patients older than 90 received more frequent PC compared to those aged 60 to 90 years (p<0.01). Those from the highest socioeconomic status were 1.7x more likely to receive PC compared to those from the lowest quartile (p<0.01). Patients who had perforation were 2.6x and 1.6x more likely to receive PC compared to those with obstruction and bowel ischemia, respectively (p<0.01). Non-operative management was associated with 2.7x increase in receiving PC vs patients undergoing surgery (p<0.01). PC was associated with lower median length of stay (4 days vs 6 days) and lower hospital charges ($26,800 vs $33,000) (p<0.01).

Conclusion: Patients with dementia and acute abdomen have high in-hospital mortality and rate of discharge to dependent care, regardless of surgical interventions. Despite this, few receive palliative care. Receipt of PC was associated with age >90, higher socioeconomic status, and having perforation as the indication for surgery. Those who had PC had fewer surgical interventions and lower intensity of treatment, suggesting that patients and their families who received PC may choose a less aggressive form of treatment in the setting of poor prognosis. The high rate of unmet palliative care needs in this population presents an opportunity for improvement in surgical care.

36.07 Study on the Validity of Pancreaticoduodenectomy in the Elderly

Posted on January 25, 2017

Y. Futagawa1, T. Kanehira1, K. Furukawa1, N. Okui1, J. Shimada1, N. Tsutsui1, Y. Fujiwara1, H. Kitamura1, S. Yoshida1, T. Usuba1, T. Nojiri1, S. Fujioka1, T. Misawa1, T. Okamoto1, K. Yanaga1  1The Jikei University School Of Medicine,Surgery,Minato-ku, TOKYO, Japan

Introduction:

~Pancreaticoduodenectomy (PD) is a radical surgical treatment for malignant biliary-pancreatic disorders. To date, indication for PD in elderly patients is determined on a case-to-case basis. However, establishing a certain standardized criteria is important as the aged population (approximately 20% in developed countries) continues to grow. The purpose of this study is to verify the outcomes of PD in the elderly.

Methods:
~We selected 340 patients with pancreatic cancer, bile duct cancer, or papilla of Vater cancer from the 436 patients who underwent PD at our four affiliated hospitals from 2003 to 2010. The subjects were divided into three groups: group A, the non-elderly (aged 64 years or younger; 60 patients with pancreatic cancer, 30 with bile duct cancer, and 25 with papilla of Vater cancer; a total of 115 subjects); group B, the early elderly (65–74 years, 75 with pancreatic cancer, 43 with bile duct cancer, and 26 with papilla of Vater cancer; a total of 144 subjects); and group C, the super-elderly (75 years or older, 43 with pancreatic cancer, 23 with bile duct cancer, and 15 with papilla of Vater cancer; a total of 81 subjects). We compared the long-term outcomes among the three groups. We also examined risk factors for a poor outcome in group C (including 11 subjects aged 81 years or older).

Results:
~The median postoperative hospital stay of groups A, B, and C was 31, 35, and 34 days, respectively (no significant differences). Mortality within 60 days postoperatively in group A was 0.9% (n = 1; liver metastasis); group B, 2.1% (n = 3; pancreatic fistula 1, bone marrow hypoplasia 1, myocardial infarction 1); and group C, 6.3% (n = 5; pseudoaneurysm rupture 1, catheter infection 1, aspiration pneumonia 1, pneumonia 1, liver metastasis 1). (P = 0.04, between groups A and C). The 3- and 5-year overall survival rate (OS) of group A was 44.7% and 38.2%, respectively; 41.6% and 25.7%, respectively for group B; and 19.8% and 9.9%, respectively for group C. (P < 0.05 between groups A and C, and between groups B and C, respectively). In group C, the 50% survival time for pancreatic cancer, bile duct cancer, and papilla of Vater cancer was 410, 820, and 757 days, respectively.  In univariate analysis, primary diseases, postoperative complications (delayed gastric emptying), stage of disease, and comorbidities (diabetes mellitus) were detected as the risk factors of poorer survival in group C.  In multivariate analysis, pancreatic cancer was a significant adverse prognostic factor (hazard ratio 3.70 in comparison with papilla of Vater cancer, P=0.04).

Conclusion:

~The validity of PD for bile duct cancer and papilla of Vater cancer was confirmed by appropriate preoperative evaluation and postoperative management in the elderly. However, the mortality associated with infectious diseases was high in the elderly. On the other hand, caution should be used for patients with pancreatic cancer, particularly advanced cases.

 

36.02 Hospital Variation in Outcomes Following Colectomies in Frail Patients

Posted on January 25, 2017

V. C. Nikolian1, N. Kamdar1, I. S. Dennahy1, S. Hendren1, D. S. Campbell1, P. Suwanabol1  1University Of Michigan Health System,General Surgery,Ann Arbor, MI, USA

Introduction:  Geriatric-specific morbidity and mortality are known to increase with frailty. Indices have been developed to predict outcomes in this population, yet it is unclear whether worse outcomes are unavoidable and related to patient factors, or modifiable and influenced by hospital factors. A paucity of data exists comparing outcomes between hospitals for frail patients undergoing colorectal surgery. Using data abstracted from medical records in a statewide surgical collaborative, we sought to determine whether risk-adjusted outcomes related to reoperations, readmissions, and mortality varied between hospitals.

Methods:  Patients ≥ 65 years old who underwent colon and rectal resections in the Michigan Surgical Quality Collaborative (MSQC) from July 2012 – June 2015 were identified. Using a previously published frailty-based surgical risk model, frailty scores were calculated by adding the components of albumin <3.4 g/dL, hematocrit <35%, serum creatinine >2 mg/dL, and ASA score >3. Bivariate analysis was conducted to determine the mean unadjusted outcome rates for each value of the frailty score. Multivariable logistic regression models were developed with frailty score and other adjustment variables as covariates in order to determine risk-adjusted outcome rates for reoperations, readmissions, and mortality. Predicted probabilities and mean unadjusted frailty scores for each hospital were calculated. Using this method, outliers were identified by comparing the MSQC adjusted outcome rates with the 95% confidence interval (CI) of each hospital. Spearman rank correlation coefficients were calculated to determine the association between hospital unadjusted frailty scores and risk adjusted outcome rates.

Results: Of 3594 colorectal resections performed in 64 Michigan hospitals, the unadjusted reoperation, readmission, and mortality rates were 9.5%, 12.2%, and 6.1%, respectively. After controlling for urgent and emergent cases, age, race, operative time, BMI, male sex, medical school affiliation, and hospital size, multivariable analysis demonstrated that outcomes were significantly worse for the most frail patients. Odds ratios of developing complications in these patients were calculated relative to those with a frailty index of 0 (ORs: reoperation: 2.54, 95% CI: 1.2-5.5; readmission: 2.5, 95 CI = 1.2-5.3; mortality: 38.4, 95% CI 8.4-175.7). There was a high degree of correlation between hospital mean frailty scores and hospital-adjusted rates of reoperations, readmissions, and mortality (Spearman rank correlation for: reoperations = 0.81, readmissions = 0.713, mortality = 0.843; p < 0.0001). Using this methodology, outliers related to each outcome were identified. 

Conclusion: Significant variation in postoperative outcomes exists between hospitals caring for frail patients. This suggests that individual hospitals are an appropriate target for interventions to improve outcomes in colorectal operations performed on frail patients.

 

35.03 The Cost Consequences of Age and Comorbidity in Accelerated Postoperative Discharge After Colectomy

Posted on January 25, 2017

S. P. Shubeck1,5,6, A. H. Cain-Nielsen1, E. Norton2,3,4, S. Regenbogen1,5  2University Of Michigan,Department Of Health Management,Ann Arbor, MI, USA 3University Of Michigan,Department Of Economics,Ann Arbor, MI, USA 4National Bureau Of Economic Research,Cambridge, MA, USA 5University Of Michigan,Center For Health Outcomes & Policy (CHOP),Ann Arbor, MI, USA 6University Of Michigan,National Clinician Scholars Program,Ann Arbor, MI, USA 1University Of Michigan,Department Of Surgery,Ann Arbor, MI, USA

Introduction: As payment for inpatient surgery transitions to bundled payments for surgical episodes, hospitals face increasing pressure to reduce utilization in and out of hospital. We previously found that early routine postoperative discharge after major surgery incurred lower total episode payments without compensatory increase in post-discharge expenditures. Whether this strategy can succeed for older patients and those with higher levels of comorbidity is unknown.

Methods: We evaluated a cross-sectional cohort of 189,229 Medicare beneficiaries 65 or older undergoing colectomy 2009-2012 and computed associations between episode payments and hospitals’ length of stay (LOS) stratified by patients’ age and health status, according to the Elixhauser Comorbidity Index. Hospitals’ LOS was characterized by the mode to reflect typical hospital practice and minimize the influence of outliers. To focus on patients adhering to hospitals’ typical care, we then restricted analysis to the 73,212 patients discharged within one day of the mode LOS for each hospital. In this cohort, we evaluated risk-adjusted, price-standardized 90-day overall episode payments including index hospitalization, outlier payments, unplanned readmissions, professional services, and post-acute care.

Results: Total episode payments were lower in shortest LOS than longest LOS hospitals in all age categories (65-69: $33,084 vs. $41,006; >=80 $32,239 vs. $42,526; both p<0.001). The oldest patients had greater post-discharge care expenditures than youngest patients, but the disparity was similar in shortest and longest LOS hospitals (+$289 vs +$1,275, p=0.20). Conversely, patients with greatest comorbidity had no reduction in total episode payments in shortest LOS hospitals ($42,848 for 3 day LOS vs. $44,647 in >=7 day LOS, p=0.06, figure). The increase in post-discharge care expenditures for patients with highest comorbidity was greater in shortest versus longest LOS hospitals (+$4,101 vs. +$1,863, p=0.002).

Conclusion: Even the oldest Medicare beneficiaries experience lower total episode payments without compensatory increase in post-acute care expenditures when undergoing colectomy in hospitals with shortest post-operative LOS pathways. In contrast, those with greatest comorbiditiy accrue no savings in short LOS hospitals as they require more post-acute care services to achieve early discharge. These findings suggest that payment reform and initiatives to improve the efficiency of perioperative care must consider overall health status more than age alone. 

35.01 Hot Spotting as a Strategy to Identify High Cost Surgical Populations

Posted on January 25, 2017

S. P. Shubeck1,2,3, M. Healy1,2, J. Thumma1,2, E. Norton4,5,6, J. Dimick1,2, H. Nathan1,2  1University Of Michigan,Department Of Surgery,Ann Arbor, MI, USA 2University Of Michigan,Center For Health Outcomes & Policy (CHOP),Ann Arbor, MI, USA 3University Of Michigan,National Clinician Scholars Program,Ann Arbor, MI, USA 4University Of Michigan,Department Of Health Management And Policy,Ann Arbor, MI, USA 5University Of Michigan,Department Of Economics,Ann Arbor, MI, USA 6National Bureau Of Economic Research,Cambridge, MA

Introduction: The Affordable Care Act’s emphasis on value over volume has signaled a shift in responsibility for healthcare costs from payers to providers. Bundled payment programs are increasingly focused on surgical procedures. Population-based management of surgical costs requires that providers can prospectively identify high cost surgical patients. This strategy, known as “hot spotting,” is well developed in medical populations, but little investigation has focused on high cost surgical patients. We sought to assess the feasibility of prospectively hot spotting high cost surgical patients.

Methods: Using 100% Medicare claims data for 2010-2013, we identified patients aged 65-99 years undergoing four elective procedures: colectomy, coronary artery bypass grafting (CABG), total hip arthroplasty (THA), or total knee arthroplasty (TKA). We calculated price-standardized Medicare payments for index hospitalization, physician services, post-acute care, and readmissions for the entire “surgical episode” from the index admission through 30 days after discharge. Patient level factors associated with payments were analyzed by multivariable linear regression.

Results: Medicare patients in the highest decile of spending accounted for a disproportionate share of aggregate costs: 30% in colectomy, 22% in CABG, 19% in THA, and 18% in TKA. Medicare expenditure differences between the highest and lowest deciles (colectomy: $75,164 vs $9,366; CABG: $77,788 vs $20,814; THA: $36,688 vs $11,406; TKA: $35,248 vs $11,647) were explained primarily by a 5-fold difference for colectomy and 3-fold difference for CABG in index hospitalization cost. In contrast, there was an 80-fold difference for THA and 47-fold difference for TKA in post-acute care expenditures between highest and lowest deciles (Figure). In multivariable analyses, patient age, gender, and socioeconomic status had minimal association with episode cost, but patients with ≥3 comorbidities had significantly higher costs compared to those with 0-1 comorbidities (colectomy: +$9,022; CABG: +$3,751; THA: +$3,172; TKA: +$2,604).

Conclusion: We found that a subset of patients was responsible for a disproportionate share of total Medicare spending for these procedures. The individual components of spending that primarily drive expenditures vary by procedure. Providers may control cost by through patient selection when spending is driven by multimorbidity, while limiting post-acute care may be effective in other procedures. These findings suggest that targeting high cost Medicare patients (i.e., hot spotting) for prehabilitation or selective referral would be a potentially effective strategy to reduce costs in surgical populations.

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