Increasing Case Volume Research Articles

Graduating Vascular Surgery Trainee Proficiency in Endovascular and Open Peripheral Revascularization Procedures

Endovascular interventions for peripheral artery disease have increased in prevalence over time given the inherent benefits of minimally invasive approaches. While it is essential that vascular surgery graduates are facile with endovascular techniques, the results of the BEST-CLI trial highlight the equivalent importance of ensuring trainee competence in open skills. Recent studies demonstrate increasing case volume of both endovascular and open procedures during vascular surgery training. Case volume is merely a surrogate marker for competence, however, and the objective competence attained by trainees at the time of graduation is unknown. We sought to investigate operative autonomy and competence of graduating vascular surgery trainees performing endovascular as compared to open peripheral vascular revascularization procedures. Operative performance and autonomy ratings for infrainguinal endovascular and open revascularizations from the Society for Improving Professional Learning Operative (SIMPL OR) application database were collected for all vascular surgery participating institutions from 2018-23. The distribution for autonomy and performance ratings were determined by training level for endovascular and open procedures, respectively. Mixed effects logistic regressions were conducted to estimate the predictive association between procedure type and autonomy and performance assessment, adjusting for training level and case complexity. Subsequently, the estimated model was applied to predict the probability of a graduating trainee being rated as meaningfully autonomous or competent while performing endovascular and open procedures across various case complexities. Sixty-nine residents from 23 programs (12 fellowship, 11 residency) were assessed on 706 revascularization procedures (n=383 endovascular, 323 open). When controlling for training level and case complexity, there were no differences in autonomy (OR 1.11 [95% CI: 0.62-1.99]) or competency assessment (OR 0.86 [95% CI: 0.46-1.59]) for endovascular, as compared to open, peripheral revascularization procedures. For average complexity procedures, the predicted probability of a trainee being assessed as competent and autonomous at the time of graduation was high (competent: 88% endovascular, 86% open; autonomous: 96% endovascular, 97% open). Predicted probability of competence and autonomy for complex procedures was lower but remained similar between groups (competent:73% endovascular, 70% open; autonomous: 92% endovascular, 92% open). There is no difference in the graduating level of autonomy and competence of endovascular as compared to open peripheral revascularization procedures for vascular surgery trainees. These findings suggest vascular surgery trainees enter independent practice with adequate proficiency to utilize the full scope of techniques to care for patients requiring peripheral revascularization procedures.

Cost Savings on Inpatient Hospitalization for Middle Meningeal Artery Embolization in the Setting of Increased Case Volume and Low Complications Rate

Middle meningeal artery(MMA) embolization for the treatment of chronic subdural hematomas(cSDH) is becoming increasingly prevalent. It is essential to optimize the safety and cost effectiveness of the post-procedural management. In this study, we examined our cases over time to determine the most appropriate post-procedural destination. This is a retrospective study of patients who underwent MMA embolization for cSDH at our institution. The study cohort was divided into two groups based on the year of embolization. Baseline characteristics, post-procedural complications, and length of stay were compared. Patients with shorter ICU stay were also compared to those with longer stay. Univariate statistical analysis was performed. 92 MMA embolizations for cSDH have been performed at our institution, of which 36(39.1%) were done between 2019 and 2022 and 56(60.9%) after 2023. No patients experienced stroke, cranial nerve palsy, or intraparenchymal hemorrhage after embolization. All but 5 patients were admitted to the intensive care unit(ICU) post-embolization, of which 59(64.1%) were downgraded after one day. Factors associated with a longer ICU stay included pre-operative location(p = 0.002) and need for surgery(p = 0.02). Of those who came from home or non-monitored bed, 82% were downgraded from the ICU in less than 2 days. The average cost of one night in the ICU, IMC, and non-monitored unit was $3,671.75, $2,605.22, and $2,303.81 respectively. MMA embolization for cSDH is a safe procedure with low rate of procedure-related complications. In carefully selected patients, the necessity ICU admission post-operatively should be weighed against better hospital resource utilization.

P1153 Hospital surgical volumes and outcomes in ileocaecal resection for Crohn’s disease in Sweden 2000-2019: A national cohort study

Abstract Background Intestinal resection for Crohn’s disease (CD) is often complex and remains associated with significant postoperative morbidity. In several other types of complex surgery, increased case volumes have been associated with better outcomes. In surgery for CD, such an association has not yet been demonstrated. Methods In this nationwide cohort study, we used the National Patient Register to identify all CD patients who underwent their first (primary) ileocaecal resection in Sweden 2000-2019 at age 15 years or above. Hospitals were grouped into low, middle, and high-volume centres based on the number of intestinal resections for CD the previous calendar year (1-24, 25-36 and ≥37 resections, respectively). Length of hospital stay, severe postoperative complications and deaths during the first 100 days after the date of index surgical admission were compared between groups, and adjusted for sex, age, duration of disease, preoperative corticosteroid therapy, and year of surgery. Rates of surgical reintervention were used as a measure of severe postoperative morbidity. Results In the 20-year study period, 3396 patients underwent primary ileocaecal resection for CD in Sweden; 2371 (69.8%), 527 (15.5%) and 498 (14.7%) in low, middle, and high-volume hospitals, respectively. Median age at surgery was 41, 39 and 34 years, respectively, and the proportion of patients with a diagnostic record of perianal disease was 9, 10 and 16%. Sex, extraintestinal manifestations and preoperative medical therapies and hospital admissions did not differ between hospital types. Laparoscopic surgery was performed in 351 (15%), 126 (24%) and 122 (24%) patients, respectively. Surgical reintervention within 100 days was performed in 117 (4.9%), 19 (3.6%) and 13 (2.6%) patients in the three groups (adjusted odds ratios 0.72 (95% confidence interval 0.43-1.15) for middle-volume and 0.52 (0.28-0.89) for high-volume hospitals, compared to low-volume hospitals, Figure). There were no differences in the length of index admission hospital stay or mortality. Conclusion In primary ileocaecal resection for CD, high-volume hospitals had lower odds of early surgical reintervention, compared to low-volume hospitals. This finding may inform considerations of subspecialisation and centralisation in surgery for Crohn’s disease.

The disproportionate impact of peer learning on emergency radiology.

The use of peer learning methods in radiology continues to grow as a means to constructively learn from past mistakes. This study examined whether emergency radiologists receive a disproportionate amount of peer learning feedback entered as potential learning opportunities (PLO), which could play a significant role in stress and career satisfaction. Our institution offers 24/7 attending coverage, with emergency radiologists interpreting a wide range of X-ray, ultrasound and CT exams on both adults and pediatric patients. Peer learning submissions entered as PLO at a single large academic medical center over a span of 3years were assessed by subspecialty distribution and correlated with the number of attending radiologists in each section. Total number of studies performed on emergency department patients and throughout the hospital system were obtained for comparison purposes. Data was assessed using analysis of variance and post hoc analysis. Emergency radiologists received significantly more (2.5 times) PLO submissions than the next closest subspeciality division and received more yearly PLO submissions per attending compared to other subspeciality divisions. This was found to still be true when normalizing for increased case volumes; Emergency radiologists received more PLO submissions per 1000 studies compared to other divisions in our department (1.59 vs. 0.85, p = 0.04). Emergency radiologists were found to receive significantly more PLO submissions than their non-emergency colleagues. Presumed causes for this discrepancy may include a higher error rate secondary to wider range of studies interpreted, demand for shorter turn-around times, higher volumes of exams read per shift, and hindsight bias in the setting of follow-up review.

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in New Zealand: peri-operative outcomes and service development over a decade.

Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is the standard of care for selected cases of peritoneal surface malignancy. However, due to its morbidity and learning curve, it is only delivered in six centres in Australia and Aotearoa New Zealand (AoNZ). In this study, we report peri-operative morbidity and mortality following CRS/HIPEC at Waikato and Braemar Hospitals, which have treated patients from all regions of AoNZ since 2008. We retrospectively reviewed a database of all patients undergoing CRS and HIPEC from 01/01/2008 to 01/11/2020 at Waikato and Braemar Hospitals. Two-hundred and forty procedures were performed for 221 patients with a mean age of 55, including 22 (9.2%) re-do procedures. One hundred and eighty-six cases were European, 32 were Māori, and 16 were Pasifika. There were 152 pseudomyxoma peritonei, 39 colorectal adenocarcinomas, 29 appendiceal cancers, 8 ovarian cancers, 6 peritoneal mesothelioma, and 6 other tumour types. The median PCI was 16. HIPEC was administered to 196 out of 196 CC0/1 cases (100%) and 3 out of 44 CC2/3 cases (6.8%). Fifty-six cases (23.3%) had at least one major complication. There were two mortalities (0.8%) within 30 days. The median length of stay was 11 days. Operative duration was identified as an independent risk factor for major complications. There was considerable variation in the number of referrals from different regions of AoNZ. Over time, a decline in major complication rate is seen with increased case volume. The Waikato region has achieved favourable short-term outcomes following CRS/HIPEC.

Increasing Value in Subspecialty Training: A Comparison of Variation in Surgical Complications for Pediatric Versus Other Fellowship-trained American Board of Orthopaedic Surgery Candidates in the Treatment of Supracondylar Fractures.

The effect of orthopaedic fellowship subspecialization on surgical complications for patients with supracondylar fracture is unknown. This study seeks to compare the effect of subspecialty training on supracondylar fracture complications. The American Board of Orthopaedic Surgery Part II Examination Case List database was reviewed for all supracondylar fractures from 1999 to 2016. Procedures were divided by fellowship subspecialty (trauma, pediatric, or other) and case volume and assessed by surgeon-reported surgical complications. Predictive factors of complications were analyzed using a binary multivariate logistic regression. Of 10,961 supracondylar fractures identified, 53.47% were done by pediatric fellowship-trained surgeons. Pediatric-trained surgeons had fewer surgical complications compared with their trauma or other trained peers (4.54%, 5.67%, and 6.24%; P = 0.001). Treatment by pediatric-trained surgeons reduced surgical complications (OR = 0.79, 95% CI: 0.66 to 0.94; P = 0.010), whereas increased case volume (31+ cases) showed no significant effect (OR = 0.79, 95% CI: 0.62 to 1.02; P = 0.068). Patient sex, age, and year of procedure did not affect complication rates, while those treated in the Southeast region of the United States and those with a complex fracture type were at increased odds. Treatment of supracondylar fractures by pediatric-trained surgeons demonstrates reduced surgeon-reported complications compared with their other fellowship-trained counterparts, whereas case volume does not. This suggests the value of fellowship training beyond pertinent surgical caseload among pediatric-trained surgeons and may lie in targeted education efforts.

An Efficiency Model for Decreasing Operative Room Turnover Time for Total Joint Arthroplasties.

Despite an increased demand for total joint arthroplasty (TJA), rising health-care costs and bundling of payments by payers have shifted the focus to improving operating room (OR) efficiency. This study aimed to assess the efficacy of an efficiency model that optimized instrument trays on decreasing OR turnover time (TOT) and the benefits made possible by this improved efficiency. All primary TJA procedures performed by a single fellowship-trained surgeon from January 2022 to August 2023 were reviewed. The surgeon partnered with Zimmer Biomet to condense the total knee and total hip arthroplasty instrument trays from seven to three trays each. Patient in OR time and patient out of OR times were collected and used to calculate TOT. Mean TOTs pre-efficiency model implementation (January - October 2022) and post-efficiency model implementation (March - August 2023) were compared. Annual cost savings were calculated based on an average cost per one minute of OR time of $47.99 and an average cost for the Sterile Processing Department (SPD) to process a single TJA tray of $79.41. Following implementation of the efficiency model, the average OR TOT significantly decreased by 19 minutes (P < 0.0001), a greater than 44% reduction in TOT. At this surgeon's current case volume, conservatively estimated at 280 primary TJA cases per year, annual savings in OR and SPD processing costs were $169,597 and $88,939, respectively. Moreover, this led to increased case volume per operative day. A small-scale intervention such as optimizing instrument trays for TJA is a valuable and sustainable solution to improve efficiency in the OR by decreasing OR TOT, thereby generating considerable cost-savings and opportunity to increase surgical volume.

Real-World Demonstration of AI to Clinical Cytometry for Rapid and Reliable Decision Support and Automated Reporting of Blood Cancers Including B-NHL and Acute Leukemias

Introduction: Flow cytometry is an integral part of routine diagnostics for hematological malignancies. Unfortunately, a decreasing number of skilled operators have to cope with increasing case volumes. The current methods are also known to produce inter- and intra-observer variability. Aim: To reduce labor time, dependency on expert knowledge and interpretation variability, we aimed to build and validate clinical-grade decision support software in the routine using machine learning (ML) for clinical cytometry. Methods: We obtained ≈100k flow cytometry cases from multiple centers, taken from clinical routine and annotated by expert users using multiple diagnostic methods. These cases span the full spectrum of hematological malignancy, including 47% non-malignant reference samples. As the data were not measured using harmonized protocols, we developed data pooling techniques to merge the data, including synthetic imputation of missing markers. After data processing, we applied multi-layer artificial neural networks to predict sub-type or non-malignancy (B-NHL and acute leukemias, ten classes at time of writing), directly from the data without any human preprocessing. Transfer learning was then used to fine-tune the model to a particular protocol for which the model could be used in routine. Besides sub-typing recommendations, users need to report cell population frequencies, traditionally measured using manual ‘gating’. We trained separate supervised ML models to classify single cells based on a combination of curated and refined routine gating data, expanded with in-house annotations produced by a highly trained cytometrist. To enable clinicians to receive the diagnostic recommendations and produce reports for the treating doctor, we built a CE-IVD web-application (“hema.to”) in which selected users could upload cytometry data, inspect the raw data including abnormalities in the immunophenotype, and audit the ML recommendations against the WHO criteria. The user feedback from each case was recorded, from which the consistency of the ML recommendations with expert opinion could be compared. Before the product was integrated in the clinical routine, a ‘dry run’ retrospective two-arm, four-center blinded clinical study using 96 randomly selected non-overlapping B-NHL cases revealed that analysis time was reduced by &amp;gt;2x and accuracy saw a slight (non-significant) increase against a gold standard as compared to the control arm with a traditional workflow. Results: A worst-case sub-typing performance was computed by testing the model against historic data without expert supervision, and found an f1 score of &amp;gt;90% and sensitivity of 96%. The ML models for acute leukemias specifically show an f1 score of ≈90%, a false positive rate of ≈1.5% and false negative rate of 2-6%. These quality metrics demonstrate that the system can be used for both screening and sub-typing. We therefore integrated hema.to into the routine for B-NHL diagnosis at Result Laboratorium (Dordrecht) and the HpH (Hamburg) since January, for the latter including a deep integration into the laboratory database with automated reporting of expressed CD markers. To date, over a thousand routine cases have been analyzed using the system. We then measured the relationship between predicted sub-typing confidence of the model and agreement with the final expert judgment. The data showed that, on average, confidence≈accuracy ( R2=0.94), indicating that the model is neither over- nor underconfident. As such, the model is a “trustworthy” classifier. Expert agreement over time revealed that the quality of the diagnostic recommendations has been stable over time despite a change of device type and was consistently in excess of 90% across various metrics, including a 100% specificity during the four most recent recorded months. Conclusions: We've shown that machine learning can offer decision support and automated reporting for screening and classifying blood cancers from flow cytometry in a real-world routine setting. Our next focus is to expand the number of indications and increase the model sensitivity to small pathological populations, including measurable residual disease. These results represent major strides towards decision support software for any lab and all hematological neoplasms. Such a software will not only speed up and simplify diagnostic workflows, but also improve the quality of the analysis.

OGBN O07 Factors in recurrence following 862 giant paraesophageal hernia repairs

Abstract Background Repair of giant paraesophageal hernia (PEH) is associated with a considerable hernia recurrence rate by objective measures. This study evaluated trends in outcomes of laparoscopic non-mesh repair of giant PEH over 30 years, and factors associated with anatomical recurrence. Methods Data was extracted from a single-surgeon prospective database of laparoscopic repair of giant PEH from 1991-2021. Upper endoscopy was performed within 12 months postoperatively and selectively thereafter. Any supra-diaphragmatic stomach was defined as anatomical recurrence. Cases were chronologically divided into tertiles with trends in casemix, operative factors and outcomes evaluated. Patient and hernia characteristics, and technical operative factors, including “composite repair” (360-degree fundoplication with esophagopexy and cardiopexy to right crus), were evaluated with univariate and multivariate analysis. Results 862 repairs met selection criteria. Mean age 69.3years, majority(65.8%) female and hernia type III(87.4%) with median hernia size 66%. There was an increasing proportion of “composite repair” after the first decade(Group1, 2.7%;Group2, 81.9%;Group3, 100%;p&amp;lt;0.001).There were less anatomical hernia recurrence(Group1, 36.6%;Group2, 22.9%;Group3, 22.7%;p&amp;lt;0.001) over time. The overall anatomical recurrence rate was 27.3% with median followup 33months(IQR 16, 68). There were 10(1.2%) Clavien-Dindo grade ≥III complications including two perioperative deaths(0.2%). Multivariate analysis identified age&amp;lt;70years, presence of Barrett’s, absence of “composite repair”, and hiatus closure under tension as independent factors associated with recurrence(HR1.27,95%CI0.88-1.82,p=0.01;HR1.58,95%CI1.12-2.23,p=0.009;HR1.72,95%CI1.2-2.44,p=0.002;HR2.05,95%CI1.33-3.17,p=0.001,respectively). Conclusions Hernia recurrence rates decreased with increasing case volume. This coincided with the increasing adoption of “composite repair”, supporting the possible improvement in recurrence rates with this approach. Repair was associated with substantial anatomical recurrence associated with patient and technique factors. Patient factors included age &amp;lt;70 years, Barrett’s esophagus, and hiatus tension. “Composite repair” was associated with lower recurrence rate.

Stability of hospital quality indicators over time: A multi-year observational study of German hospital data.

Retrospective hospital quality indicators can only be useful if they are trustworthy signals of current or future quality. Despite extensive longitudinal quality indicator data and many hospital quality public reporting initiatives, research on quality indicator stability over time is scarce and skepticism about their usefulness widespread. Based on aggregated, widely available hospital-level quality indicators, this paper sought to determine whether quality indicators are stable over time. Implications for health policy were drawn and the limited methodological foundation for stability assessments of hospital-level quality indicators enhanced. Two longitudinal datasets (self-reported and routine data), including all hospitals in Germany and covering the period from 2004 to 2017, were analysed. A logistic regression using Generalized Estimating Equations, a time-dependent, graphic quintile representation of risk-adjusted rates and Spearman's rank correlation coefficient were used. For a total of eight German quality indicators significant stability over time was demonstrated. The probability of remaining in the best quality cluster in the future across all hospitals reached from 46.9% (CI: 42.4-51.6%) for hip replacement reoperations to 80.4% (CI: 76.4-83.8%) for decubitus. Furthermore, graphical descriptive analysis showed that the difference in adverse event rates for the 20% top performing compared to the 20% worst performing hospitals in the two following years is on average between 30% for stroke and AMI and 79% for decubitus. Stability over time has been shown to vary strongly between indicators and treatment areas. Quality indicators were found to have sufficient stability over time for public reporting. Potentially, increasing case volumes per hospital, centralisation of medical services and minimum-quantity regulations may lead to more stable and reliable quality of care indicators. Finally, more robust policy interventions such as outcome-based payment, should only be applied to outcome indicators with a higher level of stability over time. This should be subject to future research.

Impact of the SARS-CoV-2 outbreak on ACGME-accredited orthopaedic trauma fellowship training

IntroductionThe SARS-CoV-2 viral outbreak created unprecedented challenges in surgical education. Yet, its impact on reported case volume during orthopaedic trauma fellowship training remains poorly understood. We hypothesized that cases performed during orthopaedic trauma fellowship training would decrease by 8 %–17 % during the 2019–2020 academic year corresponding to the 1–2 month moratorium of non-essential cases during the initial SARS-CoV-2 outbreak in the United States. MethodsWe designed a retrospective cohort study of orthopaedic trauma fellows at Accreditation Council for Graduate Medical Education (ACGME)-accredited training programs (2018–2019 to 2021–2022). Mean case volumes were compared by case category across academic years. ResultsThere was a −13 % year-over-year decrease in reported case volume during the 2019–2020 academic year (505 ± 126 vs 441 ± 94, P = 0.079, Fig. 1). Case categories with the greatest percentage declines were Treatment of Nonunion / Malunion (−31 %), Fasciotomy (−25 %), External Fixation (−21 %), Forearm / Wrist (−21 %), and Intra-articular Distal Humerus Fracture (−17 %). There was a 7 % year-over-year increase in case volume during the subsequent 2020–2021 academic year with near universal increases in case volume across case categories. ConclusionThere was a 13 % decrease in orthopaedic trauma case volume during the 2019–2020 academic year, corresponding to the SARS-CoV-2 outbreak. Certain trauma case categories experienced the greatest negative impact, which subsequently recovered during the next academic year. These results may help inform accrediting bodies and surgical educators on the impact of future viral outbreaks on orthopaedic trauma fellowship training.

Characterization of de novo malignancy after orthotopic heart transplantation: single-centre outcomes over 20 years.

Malignancy is the leading cause of late mortality after orthotopic heart transplantation (OHT), and the burden of post-transplantation cancer is expected to rise in proportion to increased case volume following the 2018 heart allocation score change. In this report, we evaluated factors associated with de novo malignancy after OHT with a focus on skin and solid organ cancers. Patients who underwent OHT at our institution between 1999 and 2018 were retrospectively reviewed (n = 488). Terminal outcomes of death and development of skin and/or solid organ malignancy were assessed as competing risks. Fine-Gray subdistribution hazards regression was used to evaluate the association between perioperative patient and donor characteristics and late-term malignancy outcomes. By 1, 5 and 10 years, an estimated 2%, 17% and 27% of patients developed skin malignancy, while 1%, 5% and 12% of patients developed solid organ malignancy. On multivariable Fine-Gray regression, age [1.05 (1.03-1.08); P < 0.001], government payer insurance [1.77 (1.20-2.59); P = 0.006], family history of malignancy [1.66 (1.15-2.38); P = 0.007] and metformin use [1.73 (1.15-2.59); P = 0.008] were associated with increased risk of melanoma and basal or squamous cell carcinoma. Age [1.08 (1.04-1.12); P < 0.001] and family history of malignancy [2.55 (1.43-4.56); P = 0.002] were associated with an increased risk of solid organ cancer, most commonly prostate and lung cancer. Vigilant cancer and immunosuppression surveillance is warranted in OHT recipients at late-term follow-up. The cumulative incidence of skin and solid organ malignancies increases temporally after transplantation, and key risk factors for the development of post-OHT malignancy warrant identification and routine monitoring.

Trends in outcomes of 862 giant hiatus hernia repairs over 30 years

PurposeLaparoscopic giant hiatus hernia repair is technically difficult with ongoing debate regarding the most effective surgical technique. Repair of small hernia has been well described but data for giant hernia is variable. This study evaluated trends in outcomes of laparoscopic non-mesh repair of giant paraesophageal hernia (PEH) over 30 years.MethodsRetrospective analysis of a single-surgeon prospective database. Laparoscopic non-mesh repairs for giant PEH between 1991 and 2021 included. Three-hundred-sixty-degree fundoplication was performed routinely, evolving into “composite repair” (esophagopexy and cardiopexy to the right crus). Cases were chronologically divided into tertiles based on operation date (Group 1, 1991–2002; Group 2, 2003–2012; Group 3, 2012–2021) with trends in casemix, operative factors and outcomes evaluated. Hernia recurrence was plotted using weighted moving average and cumulative sum (CUSUM) analysis.Results862 giant PEH repairs met selection criteria. There was an increasing proportion of “composite repair” after the first decade (Group 1, 2.7%; Group 2, 81.9%; Group 3, 100%; p < 0.001). There were less anatomical hernia recurrence (Group 1, 36.6%; Group 2, 22.9%; Group 3, 22.7%; p < 0.001) and symptomatic recurrence (Group 1, 34.2%; Group 2, 21.9%; Group 3, 7%; p < 0.001) over time. The incidence of anatomical recurrence declined over time, decreasing from 30.8% and plateauing below 17.6% near the study’s end. Median followup (months) in the first decade was higher but followup between the latter two decades comparable (Group 1, 49 [IQR 20, 81]; Group 2, 30 [IQR 15, 65]; Group 3, 24 [14, 56]; p < 0.001). There were 10 (1.2%) Clavien–Dindo grade ≥ III complications including two perioperative deaths (0.2%).ConclusionHernia recurrence rates decreased with increasing case volume. This coincided with the increasing adoption of “composite repair”, supporting the possible improvement in recurrence rates with this approach.

The impact of a dedicated operating room team on robotic transplant program growth and fellowship training.

Despite considerable interest in robotic surgery, successful incorporation of robotics into transplant programs has been challenging. Lack of a dedicated OR team with expertise in both robotics and transplant is felt to be a major barrier. This paper assesses the impact of a dedicated robotic transplant team (DART) on program growth and fellowship training at one of the largest robotic transplant programs in North America. This is a single center, retrospective review of all robotic operations performed on the transplant surgery service from October 2017 to October 2022. DART was incorporated in February 2020 and included transplant first assists (RFAs), scrub technologists and circulating nurses who received robotic training. Robotic experience before and after DART was compared to assess its impact on program growth and training. Four hundred and two robotic cases were performed by five transplant surgeons: 63 pre-DART and 339 post-DART. 40% of cases were transplant-related and 59.5%, HPB. There was a significant increase in case volume (2.5-10.6 cases/month, p<.0001) and complexity (36.5% vs. 70.3% high complexity cases, p<.0001) post-DART. RFA case coverage increased from 17% to 95%, and participation of transplant fellows as primary surgeons increased from 17% to 95% post-DART period (both p<.05). Conversion rates (9.5% vs. 4.1%) and room turn-around-times (TAT) (58.4 vs. 40.3min) were lower post-DART (p<.05). There were no emergent conversions, conversions in transplant patients, or robot-related complications in either group. OR teams with expertise in robotics and transplant surgery can accelerate growth of robotic transplant programs while maintaining patient safety.

The SEC's September spike: Regulatory inconsistency within the fiscal year

We examine whether performance reporting leads to inconsistent enforcement at the Securities and Exchange Commission (SEC). In a sample of over 13,000 SEC enforcement actions, we show that SEC staff respond to performance-reporting pressures and file more enforcement actions in September, the final month of the SEC's fiscal year, than in any other month. The increase in case volume in September is not fully explained by staff filing more procedural cases or accelerating case filings. Instead, SEC staff pursue less complex cases and agree to more lenient financial and non-financial sanctions to increase case volume in September. We attempt to rule out alternative explanations for our results, including natural SEC workflow and resource constraints. Overall, our findings suggest that performance reporting creates agency conflicts that lead to regulatory inconsistency within the fiscal year.

Socioeconomic Disparities in the Pursuit of Care at a High-Volume Institution for Surgical Resection of Vestibular Schwannomas.

Increased institutional surgical resection case volume for vestibular schwannomas (VSs) has been associated with improved patient outcomes, including reduced risk of prolonged hospital stay and readmission. Socioeconomic disparities in the pursuit of care at these high-volume institutions remain unknown. Retrospective cohort epidemiological study. National Cancer Database, a hospital-based registry of over 1,500 facilities in the United States. Adult VS patients (age, >18 years) treated surgically. High- versus low-volume facilities, defined using a facility case volume threshold of 25 cases per year. A risk-adjusted restricted cubic spline model was previously used to identify this risk threshold beyond which the incremental benefit of increasing case volume began to plateau. Sociodemographic factors, including race, ethnicity, income, insurance status, and rurality. Multivariable analyses were adjusted for patient and tumor characteristics, including age, sex, Charlson-Deyo score, and tumor size. A totoal of 10,048 patients were identified (median [interquartile range] age = 51 [41-60] years, 54% female, 87% Caucasian). Patients with Spanish/Hispanic ethnicity (OR = 0.71, 95% confidence interval [CI] = 0.52-0.96), income below median (OR = 0.63, 95% CI = 0.55-0.73]), and Medicare, Medicaid, or other government insurance versus private insurance (OR = 0.63, 95% CI = 0.53-0.74) had reduced odds of treatment at a high-volume facility. Further sensitivity analyses in which facility volume was operationalized continuously reinforced direction and significance of these associations. Socioeconomic disparities exist in the propensity for VS patients to be treated at a high-volume facility. Further work is needed to understand the nature of these associations and whether interventions can be designed to mitigate them.

The Impact of Congenital Cardiac Surgery Fellowship on Training and Practice

BackgroundIn 2007, congenital cardiac surgery became a recognized fellowship by the American Council of Graduate Medical Education (ACGME). Beginning in 2023, the fellowship transitioned from a 1-year to a 2-year program. Our objective is to provide current benchmarks by surveying current training programs and assessing characteristics contributing to career success. MethodsThis was a survey-based study in which tailored questionnaires were distributed to program directors (PDs) and graduates of the ACGME accredited training programs. Data collection included responses to multiple-choice and open-ended questions relevant to didactics, operative training, training center characteristics, mentorship, and employment characteristics. Results were analyzed using summary statistics and subgroup and multivariable analyses. ResultsThe survey yielded responses from 13 of 15 PDs (86%) and 41 of 101 graduates (41%) from ACGME accredited programs. Perceptions among PDs and graduates were somewhat discordant, with PDs more optimistic than graduates. Of PDs, 77% (n = 10) believed current training adequately prepares fellows and is successful in securing employment for graduates. The responses from graduates demonstrated 30% (n = 12) were dissatisfied with operative experience and 24% (n = 10) with overall training. Being supported during the first 5 years of practice was significantly associated with retention in congenital cardiac surgery and greater practicing case volumes. ConclusionsDichotomous views exist between graduates and PDs regarding success in training. Mentorship during the early career was associated with increased case volumes, career satisfaction, and retention in the congenital cardiac surgery field. Educational bodies should incorporate these elements during training and after graduation.

Center case volume is associated with Society of Thoracic Surgeons–defined failure to rescue in cardiac surgery

ObjectiveOur understanding of the impact of a center's case volume on failure to rescue (FTR) after cardiac surgery is incomplete. We hypothesized that increasing center case volume would be associated with lower FTR. MethodsPatients undergoing a Society of Thoracic Surgeons index operation in a regional collaborative (2011-2021) were included. After we excluded patients with missing Society of Thoracic Surgeons Predicted Risk of Mortality scores, patients were stratified by mean annual center case volume. The lowest quartile of case volume was compared with all other patients. Logistic regression analyzed the association between center case volume and FTR, adjusting for patient demographics, race, insurance, comorbidities, procedure type, and year. ResultsA total of 43,641 patients were included across 17 centers during the study period. Of these, 5315 (12.2%) developed an FTR complication, and 735 (13.8% of those who developed an FTR complication) experienced FTR. Median annual case volume was 226, with 25th and 75th percentile cutoffs of 136 and 284 cases, respectively. Increasing center-level case volume was associated with significantly greater center-level major complication rates but lower mortality and FTR rates (all P values < .01). Observed-to-expected FTR was significantly associated with case volume (P = .040). Increasing case volume was independently associated with decreasing FTR rate in the final multivariable model (odds ratio, 0.87 per quartile; confidence interval, 0.799-0.946, P = .001). ConclusionsIncreasing center case volume is significantly associated with improved FTR rates. Assessment of low-volume centers' FTR performance represents an opportunity for quality improvement.

Comparing Trends in Medicare Reimbursement and Inflation within Plastic Surgery Subspecialties.

Over the past decade across multiple surgical specialties, Medicare reimbursement rates have remained stagnant, failing to keep pace with inflation. An internal comparison of subspecialties within plastic surgery has not yet been attempted. The goal of this study was to investigate the trends in reimbursement from 2010 to 2020 and compare across the subspecialties of plastic surgery. The Physician/Supplier Procedure Summary was used to extract the annual case volume for the top 80% most-billed CPT codes within plastic surgery. Codes were defined into the following subspecialties: microsurgery, craniofacial surgery, breast surgery, hand surgery, and general plastic surgery. The Medicare physician reimbursement was weighted by case volume. The growth rate and compound annual growth rate were calculated and compared against an inflation-adjusted reimbursement value. On average, inflation-adjusted growth in reimbursement for the procedures analyzed in this study was -13.5%. The largest decrease in growth rate was within the field of microsurgery (-19.2%), followed by craniofacial surgery (-17.6%). These subspecialties also had the lowest compound annual growth rate (-2.11% and -1.91%, respectively). For case volumes, microsurgery increased case volumes by an average of 3% per year, whereas craniofacial surgery increased case volumes by an average of 5% per year. After adjusting for inflation, all subspecialties had a decrease in growth rate. This was particularly evident in the fields of craniofacial surgery and microsurgery. Consequently, practice patterns and patient access may be negatively affected. Further advocacy and physician participation in reimbursement rate negotiation may be essential to adjust for variance and inflation.

PO-02-195 ADJUNCTIVE VEIN OF MARSHALL ETHANOL ABLATION FOR ATRIAL FIBRILLATION: SINGLE CENTER EXPERIENCE AND PROCEDURAL LEARNING CURVE

Retrograde ethanol infusion into the vein of Marshall (EI-VOM) has been demonstrated to be an effective adjunct to pulmonary vein isolation (PVI) for ablation of atrial fibrillation (AF). This study sought to assess the temporal change in procedural volume and associated success rate of VOM ethanol ablation. All patients undergoing PVI with EI-VOM at The Ohio State University Wexner Medical Center from January 2021 to November 2022 were included. Procedural success was defined as successful retrograde infusion of ethanol into the vein of Marshall followed the development of a characteristic distribution of low voltage scar in a semicircular pattern around the left inferior pulmonary vein on high-density electroanatomical mapping. The scar was adjudicated by two blinded high-volume operators. The primary endpoint was procedural success over 6-month intervals. Statistical significance was assessed via Fisher's exact test. 201 patients underwent attempted EI-VOM. Patient characteristics were notable for age 65.2 ± 9.0 years, 56 (28%) females, body mass index 33.1 ± 7.3 kg/m2, left ventricular ejection fraction 52.3 ± 11.3%, and CHA2DS2-VASc 2.9 ± 1.5. 113 (56%) patients had non-paroxysmal AF. 173 (86%) patients had failed antiarrhythmic drugs, 113 (56%) patients had a prior cardioversion, and 105 (52%) patients had a prior catheter ablation for AF. Over 23 months, procedural volume increased from an average of 2 cases/month to 12 cases/month, and the procedural success rate increased from 33% to 68% (p=0.020). Figure 1 demonstrates the case volume and procedural learning curve over time. Notable complications included 1 (0.5%) case of cardiac tamponade requiring pericardiocentesis. VOM ethanol ablation is associated with a significant learning curve, and procedural success rate significantly improves with increased case volume.