Surgeon Performance Research Articles

New surgery technique combining robotics and laparoscopy using the Hugo™ RAS system.

Hybrid total laparoscopic hysterectomy combines conventional laparoscopic surgery and robot-assisted devices: the camera and assistant forceps are operated by a robotic device, whereas the surgeon performs laparoscopic procedures, enabling surgery with a completely fixed field of view and significantly reducing errors in forceps grasping and needle misalignment. Here, we examined whether using two arms of the Hugo™ robot-assisted surgery system, one for the camera and one for the assistant, would improve surgical accuracy compared with conventional total laparoscopic hysterectomy. The surgical system reduced surgeon errors in grasping the forceps during training and stabilized forceps operation. Compared with conventional laparoscopic surgery, the use of the surgical system did not result in different operative durations. The stable surgical procedure was considered a major advantage. This new technique involving new equipment can improve surgeon training and performance. In the future, we will develop new techniques to improve surgical performance.

Training outcomes of novice clinicians in the use of dynamic computer assisted implant surgery: A prospective comparative study

Background/PurposeThe increasing importance of computer assisted implant surgery (CAIS) in the practice of implant dentistry calls for adequate education and training of clinicians. However, limited evidence exists to support optimal educational strategies and best practices. This study aimed to investigate the effectiveness of distributed training with dynamic CAIS (d-CAIS) on the precision of freehand implant placement by inexperienced operators. Materials and methodsSix senior undergraduate dental students underwent simulation training in freehand implant surgery (5 implants) followed by distributed training in d-CAIS (6 implants). A final assessment of freehand implant placement (5 implants) was conducted thereafter. Outcomes were compared to a benchmark set by an experienced surgeon who repeated the same simulation exercises. Total surgical time and implant placement precision were recorded. ResultsThe average precision of implant placement improved significantly after the d-CAIS training for novice operators. 3D platform deviation (1.63 ± 0.85 vs 0.92 ± 0.23; P < 0.001), 3D apical deviation (1.93 ± 0.88 vs 1.21 ± 0.19; P < 0.001), and angular deviation (5.27 ± 2.30 vs 2.74 ± 1.37; P < 0.001). The students achieved platform deviation comparable to this of the expert, but lagged in angle, apex precision, and total surgical time. ConclusionShort-term, distributed simulation training with d-CAIS can significantly enhance the precision of freehand implant placement by novice operators. However, novice operators still lagged at certain aspects of precision and surgical time when compared with the performance of an experienced surgeon in the same setup.

Impact of an AI-Based laparoscopic cholecystectomy coaching program on the surgical performance: a randomized controlled trial.

Laparoscopic cholecystectomy (LC) is the gold standard for treating symptomatic gallstones but carries inherent risks like bile duct injury (BDI). While critical view of safety (CVS) is advocated to mitigate BDI, its real-world adoption is limited. Additionally, significant variations in surgeon performance impede procedural standardization, highlighting the need for a feasible, innovative, and effective training approach. The aim of this study is to develop an Artificial Intelligence (AI)-assisted coaching program for LC to enhance surgical education and improve surgeon's performance. We conducted a multi-center, randomized controlled trial from May 2022 to August 2023 to assess the impact of an AI-based coaching program, SmartCoach, on novice performing LC. Surgeons and patients meeting specific inclusion criteria were randomly assigned to either a coaching group with AI-enhanced feedback or a self-learning group. The primary outcome was assessed using the Laparoscopic Cholecystectomy Rating Form (LCRF), with secondary outcomes including surgical safety, efficiency, and adverse events. Statistical analyses were performed using SPSS, with significance set at P-value less than 0.05. Between May 2022 and August 2023, 22 surgeons were initially enrolled from 10 hospitals, with 18 completing the study. No demographic differences were noted between coaching and self-learning groups. In terms of surgical performance (LCRF scores), the coaching group showed significant improvement over time (31 to 40, P=0.008), outperforming the self-learning group by study end (40 vs 38, P=0.032). Significant improvements in CVS achievement were also noted in the coaching group (11% to 78%, P=0.021). Overall, the coaching program was well-received, outpacing traditional educational methods in both understanding and execution of CVS and participants in the intervention group expressed strongly satisfaction with the program. The AI-assisted surgical coaching program effectively improved surgical performance and safety for novice surgeons in LC procedures. The model holds significant promise for advancing surgical education.

Comparative Study of Ergonomics in Conventional and Robotic-Assisted Laparoscopic Surgery.

This study aims to implement a set of wearable technologies to record and analyze the surgeon's physiological and ergonomic parameters during the performance of conventional and robotic-assisted laparoscopic surgery, comparing the ergonomics and stress levels of surgeons during surgical procedures. This study was organized in two different settings: simulator tasks and experimental model surgical procedures. The participating surgeons performed the tasks and surgical procedures in both laparoscopic and robotic-assisted surgery in a randomized fashion. Different wearable technologies were used to record the surgeons' posture, muscle activity, electrodermal activity and electrocardiography signal during the surgical practice. The simulator study involved six surgeons: three experienced (>100 laparoscopic procedures performed; 36.33 ± 13.65 years old) and three novices (<100 laparoscopic procedures; 29.33 ± 8.39 years old). Three surgeons of different surgical specialties with experience in laparoscopic surgery (>100 laparoscopic procedures performed; 37.00 ± 5.29 years old), but without experience in surgical robotics, participated in the experimental model study. The participating surgeons showed an increased level of stress during the robotic-assisted surgical procedures. Overall, improved surgeon posture was obtained during robotic-assisted surgery, with a reduction in localized muscle fatigue. A set of wearable technologies was implemented to measure and analyze surgeon physiological and ergonomic parameters. Robotic-assisted procedures showed better ergonomic outcomes for the surgeon compared to conventional laparoscopic surgery. Ergonomic analysis allows us to optimize surgeon performance and improve surgical training.

Cutting-edge care: unleashing artificial intelligence's potential in gynecologic surgery.

Artificial intelligence (AI) is now integrated in our daily life. It has also been incorporated in medicine with algorithms to diagnose, recommend treatment options, and estimate prognosis. AI in surgery differs from virtual AI used for clinical application. Physical AI in the form of computer vision and augmented reality is used to improve surgeon's skills, performance, and patient outcomes. Several applications of AI and augmented reality are utilized in gynecologic surgery. AI's potential use can be found in all phases of surgery: preoperatively, intra-operatively, and postoperatively. Its current benefits are for improving accuracy, surgeon's precision, and reducing complications.

Putting the ready in readiness: A post hoc analysis of surgeon performance during a military mass casualty situation in Afghanistan.

All military surgeons must maintain trauma capabilities for expeditionary care contexts, yet most are not trauma specialists. Maintaining clinical readiness for trauma and mass casualty care is a significant challenge for military and civilian surgeons. We examined the effect of a prescribed clinical readiness program for expeditionary trauma care on the surgical performance of 12 surgeons during a 60-patient mass-casualty situation (MASCAL). The sample included orthopedic (four) and general surgeons (eight) who cared for MASCAL victims at Hamad Karzai International Airport, Kabul, Afghanistan, on August 26, 2021. One orthopedic and two general surgeons had prior deployment experience. The prescribed program included three primary measures of clinical readiness: 1, expeditionary knowledge (examination score); 2, procedural skills competencies (performance assessment score); and 3, clinical activity (operative practice profile metric). Data were attained from program records for each surgeon in the sample. Each of the 60 patient cases was reviewed and rated (performance score) by the Joint Trauma System's Performance Improvement Branch, a military-wide performance improvement organization. All scores were normalized to facilitate direct comparisons using effect size calculations between each predeployment measure and MASCAL surgical care. Predeployment knowledge and clinical activity measures met program benchmarks. Baseline predeployment procedural skills competency scores did not meet program benchmarks; however, those gaps were closed through retraining, ensuring all surgeons met or exceeded the program benchmarks predeployment. There were very large effect sizes (Cohen's d ) between all program measures and surgical care score, confirming the relationship between the program measures and MASCAL trauma care provided by the 12 surgeons. The prescribed program measures ensured that all surgeons achieved predeployment performance benchmarks and provided high-quality trauma care to our nation's service members. Prognostic and Epidemiological; Level IV.

A Method for Continuous Surgeon Improvement in Rectal Cancer: Risk-Adjusted Cumulative Sum.

To develop and analyze a risk-adjusted cumulative sum (RA-CUSUM) chart as a potential method to monitor individual surgeon performance in robotic total mesorectal excision (TME) for rectal cancer. Currently, surgeons lack real-time tools to monitor and enhance their performance beyond residency completion. While national quality programs exist, granular, individual-level data is crucial for continuous improvement. Previous studies suggest CUSUM charts hold promise in identifying performance trends and outliers. This retrospective study analyzed data from 640 robotic TME cases performed by 12 surgeons at two institutions. RA-CUSUM charts were generated for three outcomes: complications, operative time, and length of stay. The overall RA-CUSUM curves for operative time and complications showed an initial learning phase followed by a plateau or downward slope, indicating proficiency or improvement. However, individual surgeon curves revealed significant heterogeneity. Three surgeons consistently excelled in operative time, while five minimized complications most effectively. Potential quality improvement could be implemented to drive performance toward positive outliers. No differences were found in unadjusted outcomes, including conversion, number of lymph nodes harvested, and positive circumferential margins. The RA-CUSUM chart is a promising method for identifying individual surgeon performance in robotic TME. It could help surgeons, teams, and leaders identify improvement areas and benchmark themselves against positive outliers. Further studies are needed to explore the potential of RA-CUSUM for implementing interventions to improve surgical quality.

Assessing Endoscopic Response in Locally Advanced Rectal Cancer Treated with Total Neoadjuvant Therapy: Development and Validation of a Highly Accurate Convolutional Neural Network.

Rectal tumors display varying degrees of response to total neoadjuvant therapy (TNT). We evaluated the performance of a convolutional neural network (CNN) in interpreting endoscopic images of either a non-complete response to TNT or local regrowth during watch-and-wait surveillance. Endoscopic images from stage II/III rectal cancers treated with TNT from 2012 to 2020 at a single institution were retrospectively reviewed. Images were labelled as Tumor or No Tumor based on endoscopy timing (before, during, or after treatment) and the tumor's endoluminal response. A CNN was trained using ResNet-50 architecture. The area under the curve (AUC) was analyzed during training and for two test sets. The main test set included images of tumors treated with TNT. The other contained images of local regrowth. The model's performance was compared to sixteen surgeons and surgical trainees who evaluated 119 images for evidence of tumor. Fleiss' kappa was calculated by respondent experience level. A total of 2717 images from 288 patients were included; 1407 (51.8%) contained tumor. The AUC was 0.99, 0.98, and 0.92 for training, main test, and local regrowth test sets. The model performed on par with surgeons of all experience levels for the main test set. Interobserver agreement was good ( = 0.71-0.81). All groups outperformed the model in identifying tumor from images of local regrowth. Interobserver agreement was fair to moderate ( = 0.24-0.52). A highly accurate CNN matched the performance of colorectal surgeons in identifying a noncomplete response to TNT. However, the model demonstrated suboptimal accuracy when analyzing images of local regrowth.

Accuracy of surgeons for predicting radiological sarcopenia in colorectal cancer surgery.

This study explored the performance of surgeons for predicting radiological sarcopenia as accessed by psoas cross-sectional area in patients with colorectal cancer (CRC). A cross-sectional study was carried out and a diagnostic accuracy strategy was applied using the radiologist team assessment as gold standard. Cohort analysis of 45 consecutive patients found that 31.1% had sarcopenia. Correlation of Total Psoas Index between radiologists and surgeons was very strong for the Junior and strong for the Senior surgeon, with a strong correlation between the surgeons. By the simplistic criterion, agreement between radiologists and surgeons was substantial for both the Junior and Senior surgeons, with a moderate level between the surgeons. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of Junior surgeon were 92.9%, 83.9%, 72.2%, 96.3%, and 86.7%, respectively. The corresponding results for the Senior surgeon were 78.6%, 90.3%, 78.6%, 90.3%, and 86.7%, respectively. We found no major differences on agreement levels and performance of surgeons using the composite criterion. Surgeons seem to be accurate for identifying radiological sarcopenia in patients with CRC. The simplistic criterion should be preferred since a composite criterion adds complexity without increasing accuracy or agreement levels.

Optimized reusable modular 3D-printed models of choledochal cyst to simulate laparoscopic and robotic bilioenteric anastomosis

Laparoscopic and robotic surgery is a challenge to the surgeon's hand–eye coordination ability, which requires constant practice. Traditional mentor training is gradually shifting to simulation training based on various models. Laparoscopic and robotic bilioenteric anastomosis is an important and difficult operation in hepatobiliary surgery. We constructed and optimized the reusable modular 3D-printed models of choledochal cyst. The aim of this study was to verify the ability of this optimized model to distinguish between surgeons with different levels of proficiency and the benefits of repeated practice. A total of 12 surgeons with different levels participated in the study. Operation completion time and OSATS score were recorded. The model was validated by Likert scale. Surgeons were shown the steps and contents before performing laparoscopic or robotic bilioenteric anastomosis using the model. Surgeons with different levels of experience showed different levels when performing laparoscopic bilioenteric anastomosis on this model. Repeated training can significantly shorten the time of laparoscopic bilioenteric anastomosis and improve the operation scores of surgeons with different levels of experience. At the same time, preliminary results have shown that the performance of surgeons on the domestic robotic platform was basically consistent with their laparoscopic skills. This model may distinguish surgeons with different levels of experience and may improve surgical skills through repeated practice. It is worth noting that in order to draw more reliable conclusions, more subjects should be collected and more experiments should be done in the future.

Detection of Residual Peritoneal Metastases Following Cytoreductive Surgery Using Pegsitacianine, a pH-Sensitive Imaging Agent: Final Results from a Phase II Study.

For patients with peritoneal carcinomatosis, extent of disease and completeness of cytoreductive surgery (CRS) are major prognostic factors for long-term survival. Assessment of these factors could be improved using imaging agents. Pegsitacianine is a pH-sensitive polymeric micelle conjugated to thefluorophore indocyanine green. The micelle disassembles in acidic microenvironments, such as tumors, resulting in localized fluorescence unmasking. We assessed the utility of pegsitacianine in detecting residual disease following CRS. NCT04950166 was a phase II, non-randomized, open-label, multicenter US study. Patients eligible for CRS were administered an intravenous dose of pegsitacianine at 1 mg/kg 24-72 h before surgery. Following CRS, the peritoneal cavity was reexamined under near-infrared (NIR) illumination to evaluate for fluorescent tissue. Fluorescent tissue identified was excised and evaluated by histopathology. The primary outcome was the rate of clinically significant events (CSE), defined as detection of histologically confirmed residual disease excised with pegsitacianine or a revision in the assessment of completeness of CRS. Secondary outcomes included acceptable safety and pegsitacianine performance. A total of 53 patients were screened, 50 enrolled, and 40 were evaluable for CSE across six primary tumor types. Residual disease was detected with pegsitacianine in 20 of 40 (50%) patients. Pegsitacianine showed high sensitivity and was well tolerated with no serious adverse events (SAEs). Transient treatment-related, non-anaphylactic infusion reactions occurred in 28% of patients. Pegsitacianine was well tolerated and facilitated the recognition of occult residual disease following CRS. The high rate of residual disease detected suggests that the use of pegsitacianine augmented surgeon assessment and performance during CRS.

Feasibility and potential of intraoperative ultrasound in arthroscopy of femoroacetabular impingement

ABSTRACT This study aimed to evaluate the feasibility of using ultrasound for monitoring osteochondroplasty intraoperatively, determine the factors that interfere with ultrasound imaging and assess its influence on surgeon performance. Intraoperative ultrasonography was performed during osteochondroplasty in 39 cases of arthroscopy. The femoral head–neck junction (FHNJ) was evaluated using ultrasonography. Another 39 cases, which underwent conventional arthroscopy, were included in the control group. The C-arm was used in this group at the end of osteochondroplasty to confirm that no residual cam lesion remained. Pre- and postoperative Dunn radiographs and computed tomography (CT) scans were analyzed to determine the feasibility of ultrasound. Residual cam deformity was noted in eight cases under ultrasound. The FHNJ was not detected owing to ultrasound interference by air in three cases. No difference in the α angle measured in Dunn radiographs and the residual cam deformity rate of CT at the 1:00, 2:00 or 3:00 position was found between both groups. However, the α angle at the 3:00 position was greater in the ultrasound group than in the control group (44.4 ± 4.3° versus 41.3 ± 5.1°, P &amp;lt; 0.05), suggesting that more bone was preserved at 3:00 in the ultrasound group. No difference was found in the mean operation time. None of the patients experienced complications, such as wounds or intra-articular infections. Ultrasound is a safe method for assessing FHNJ during arthroscopy. It did not change the risk of residual cam deformity but positively affected the surgeon’s performance by reducing unnecessary bone removal.

Merit-Based Incentive Payment System: How Are Plastic Surgeons Performing?

Merit-based incentive payment system (MIPS) is a payment model implemented to promote high-value care through performance-based adjustments of Medicare reimbursements. Higher scores indicate superior performance in healthcare quality, efficiency, and interoperability, which can result in financial advantages. Given the paucity of literature, we aimed to characterize plastic surgery performance in MIPS. The Centers for Medicare and Medicaid Services (CMS) online data repository was queried for data on MIPS performance of plastic surgeons from 2019-2021. Descriptive analyses and multivariable logistic regression were conducted to identify predictors of receiving bonus payment for exceptional performance. Approximately 1400 surgeons were sampled in each year. The median number of Medicare beneficiaries and percent of dually eligible beneficiaries-eligible for Medicare and Medicaid-were higher in 2019 (p<0.001). Beneficiary median HCC risk score, which measures expected healthcare costs and needs based on health status, was lower in 2021 (p<0.001). The most common reporting schema was reporting as a group. Total MIPS score increased from 2019 to 2020 to 2021 (90.2 vs 96.4 vs 98.3, p<0.001), but quality score progressively decreased (98.8 vs 95.5 vs 89.90, p<0.001). Fewer physicians received positive adjustment and bonus payments in 2020 and 2021. Predictors of receiving bonus payments were reporting as an alternative payment model, practice size >24, and having 10-49% of dually eligible beneficiaries (p<0.05). Understanding performance of plastic surgeons in MIPS can guide future policy direction and ensure that high-quality care translates into improved patient outcomes across all fields and levels of social vulnerability.

Evaluating colonoscopy quality by performing provider type.

Colorectal cancer is the third most diagnosed cancer and the second leading cause of cancer death in the United States. Colonoscopy is an essential tool for screening, used as a primary approach and follow-up to an abnormal stool-based colorectal cancer screening result. Colonoscopy quality is often measured with 4 key indicators: bowel preparation, cecal intubation, mean withdrawal time, and adenoma detection. Colonoscopies are most often performed by gastroenterologists (GI), however, in rural and medically underserved areas, non-GI providers often perform colonoscopies. This study aims to evaluate the quality and safety of screening colonoscopies performed by non-GI practitioner, comparing their outcomes with those of GI providers. Descriptive statistics were used to characterize the study population. Results for quality indicators were stratified by provider type and compared. Statistical significance was determined using a P value of less than .05 as the threshold for all comparisons; all P values were 2-sided. No statistical difference was found when comparing performance by provider type. Median performance for gastroenterologists, general surgeons, and family medicine providers ranged from 98% to 100% for cecal intubation; 97.4% to 100% for bowel preparation; 57.4% to 88.9% for male adenoma detection rate; 47.7% to 62.13% for female adenoma detection rate; and 0:12:10 to 0:20:16 for mean withdrawal time. All provider types met and exceeded the goal metric for each of the quality indicators (P < .001). As a result of this analysis, we can expect non-GI practitioner to perform colonoscopies with similar quality to GI practitioner given the performance outcomes for the key quality metrics.

ChatGPT performance on the American Shoulder and Elbow Surgeons maintenance of certification exam

BackgroundWhile multiple studies have tested the ability of large language models (LLM), such as ChatGPT, to pass standardized medical exams at different levels of training, LLMs have never been tested on surgical sub-specialty examinations, such as the American Shoulder and Elbow Surgeons (ASES) Maintenance of Certification (MOC). The purpose of this study was to compare results of ChatGPT 3.5, GPT-4, and fellowship-trained surgeons on the 2023 American Shoulder and Elbow Surgeons (ASES) Maintenance of Certification (MOC) self-assessment exam. MethodsChatGPT 3.5 and GPT-4 were subjected to the same set of text-only questions from the ASES MOC exam, and GPT-4 was additionally subjected to image-based MOC exam questions. Question responses from both models were compared against the correct answers. Performance of both models was compared to corresponding average human performance on the same question subsets. One sided proportional z-test were utilized to analyze data. ResultsHumans performed significantly better than Chat GPT 3.5 on exclusively text-based questions (76.4% vs. 60.8%, p= .044). Humans also performed significantly better than GPT 4 on image-based questions (73.9% vs. 53.2%, p= .019). There was no significant difference between humans and GPT 4 in text-based questions (76.4% vs. 66.7%, p=0.136). Accounting for all questions, humans significantly outperformed GPT-4 (75.3% vs. 60.2%, p= .012). GPT-4 did not perform statistically significantly betterer than ChatGPT 3.5 on text-only questions (66.7% vs. 60.8%, p= .268). DiscussionAlthough human performance was overall superior, ChatGPT demonstrated the capacity to analyze orthopedic information and answer specialty-specific questions on the ASES MOC exam for both text and image-based questions. With continued advancements in deep learning, large language models may someday rival exam performance of fellowship-trained surgeons.

Use of surgical procedure manager to standardise operation steps and monitor surgeon performance in open repair of inguinal hernia

AbstractObjectivesTo study the feasibility of using surgical procedure manager (SPM), a digital checklist platform, to standardise surgical steps of open hernia repair and monitor the operative performance.MethodologyA retrospective study on all open mesh repair of inguinal hernia under local anaesthesia from September 2019 to November 2021 at the Prince of Wales Hospital was performed. The operative outcomes of patients having operations with or without the use of SPM were compared. Procedures using SPM had operation steps shown as a digital checklist inside the theatre. The time used for each surgical step was recorded and analysed. The operative performance of the surgeons was analysed by observing the trend of the mean operation time over time.ResultsA total of 123 patients were recruited, of which 52 were using the SPM. The median age of patients was 75 (range 49–93) years. A decreasing trend in the mean operation time for dissection, mesh placement, wound closure and total operation time was observed in surgeries using SPM. There was no significant difference in the operation time, theatre time, total length of stay, blood loss and readmission rate between the SPM and non‐SPM groups. The proportion of basic surgical trainees as coached surgeons in the SPM group was significantly higher (SPM = 52% vs non‐SPM = 28%, P = .07).ConclusionsThe use of SPM did not significantly prolong the operation time and produce comparable operative outcomes in open hernia repair. It provided the additional advantage of standardising operation steps and monitoring the performance of surgical trainees during their training.

Surgeon Performance as a Predictor for Patient-Reported Outcomes After Arthroscopic Partial Meniscectomy.

Surgeon performance has been investigated as a factor affecting patient outcomes after orthopaedic procedures to improve transparency between patients and providers. The purpose of this study was to identify whether surgeon performance influenced patient-reported outcomes (PROMs) 1 year after arthroscopic partial meniscectomy (APM). It was hypothesized that there would be no significant difference in PROMs between patients who underwent APM from various surgeons. Case-control study; Level of evidence, 3. A prospective cohort of 794 patients who underwent APM between 2018 and 2019 were included in the analysis. A total of 34 surgeons from a large multicenter health care center were included. Three multivariable models were built to determine whether the surgeon-among demographic and meniscal pathology factors-was a significant variable for predicting the Knee injury and Osteoarthritis Outcome Score (KOOS)-Pain subscale, the Patient Acceptable Symptom State (PASS), and a 10-point improvement in the KOOS-Pain at 1 year after APM. Likelihood ratio (LR) tests were used to determine the significance of the surgeon variable in the models. The 794 patients were identified from the multicenter hospital system. The baseline KOOS-Pain score was a significant predictor of outcome in the 1-year KOOS-Pain model (odds ratio [OR], 2.1 [95% CI, 1.77-2.48]; P < .001), the KOOS-Pain 10-point improvement model (OR, 0.57 [95% CI, 0.44-0.73), and the 1-year PASS model (OR, 1.42 [95% CI, 1.15-1.76]; P = .002) among articular cartilage pathology (bipolar medial cartilage) and patient-factor variables, including body mass index, Veterans RAND 12-Item Health Survey-Mental Component Score, and Area Deprivation Index. The individual surgeon significantly impacted outcomes in the 1-year KOOS-Pain mixed model in the LR test (P = .004). Patient factors and characteristics are better predictors for patient outcomes 1 year after APM than surgeon characteristics, specifically baseline KOOS-Pain, although an individual surgeon influenced the 1-Year KOOS-Pain mixed model in the LR test. This finding has key clinical implications; surgeons who wish to improve patient outcomes after APM should focus on improving patient selection rather than improving the surgical technique. Future research is needed to determine whether surgeon variability has an impact on longer-term patient outcomes.

Using risk-adjusted cumulative sum to evaluate surgeon, divisional, and institutional outcomes—a feasibility study

BackgroundFew objective, real-time measurements of surgeon performance exist. The risk-adjusted cumulative sum is a novel method that can track surgeon-level outcomes on a continuous basis. The objective of this study was to demonstrate the feasibility of using risk-adjusted cumulative sum to monitor outcomes after colorectal operations and identify clinically relevant performance variations. MethodsThe National Surgical Quality Improvement Program was queried to obtain patient-level data for 1,603 colorectal operations at a high-volume center from 2011 to 2020. For each case, expected risks of morbidity, mortality, reoperation, readmission, and prolonged length of stay were estimated using the National Surgical Quality Improvement Program risk calculator. Risk-adjusted cumulative sum curves were generated to signal observed-to-expected odds ratios of 1.5 (poor performance) and 0.5 (exceptional performance). Control limits were set based on a false positive rate of 5% (α = 0.05). ResultsThe cohort included data on 7 surgeons (those with more than 20 cases in the study period). Institutional observed versus expected outcomes were the following: morbidity 12.5% (vs 15.0%), mortality 2.5% (vs 2.0%), prolonged length of stay 19.7% (vs 19.1%), reoperation 11.1% (vs 11.3%), and 30-day readmission 6.1% (vs 4.8%). Risk-adjusted cumulative sum accurately demonstrated within- and between-surgeon performance variations across these metrics and proved effective when considering division-level data. ConclusionRisk-adjusted cumulative sum adjusts for patient-level risk factors to provide real-time data on surgeon-specific outcomes. This approach enables prompt identification of performance outliers and can contribute to quality assurance, root-cause analysis, and incentivization not only at the surgeon level but at divisional and institutional levels as well.

Operating Room Supply Cost and Value of Care after Implementing a Sustainable Quality Intervention.

Variability in operating room supply cost is a modifiable cause of suboptimal resource use and low value of care (outcomes vs cost). This study describes implementation of a quality improvement intervention to decrease operating room supply costs. An automated electronic health record data pipeline harmonized operating room supply cost data with patient and case characteristics and outcomes. For inpatient procedures, predicted mortality and length of stay were used to calculate observed-to-expected ratios and value of care using validated equations. For commonly performed (1 or more per week) procedures, the pipeline generated figures illustrating individual surgeon performance vs peers, costs for each surgeon performing each case type, and control charts identifying out-of-control cases and surgeons with more than 90th percentile costs, which were shared with surgeons and division chiefs alongside guidance for modifying case-specific supply instructions to operating room nurses and technicians. Preintervention control (1,064 cases for 7 months) and postintervention (307 cases for 2 months) cohorts had similar baseline characteristics across all 16 commonly performed procedures. Median costs per case were lower in the intervention cohort ($811 [$525 to $1,367] vs controls: $1,080 [$603 to $1,574], p < 0.001), as was the incidence of out-of-control cases (19 (6.2%) vs 110 (10.3%), p = 0.03). Duration of surgery, length of stay, discharge disposition, and 30-day mortality and readmission rates were similar between cohorts. Value of care was higher in the intervention cohort (1.1 [0.1 to 1.5] vs 1.0 [0.2 to 1.4], p = 0.04). Pipeline runtime was 16:07. An automated, sustainable quality improvement intervention was associated with decreased operating room supply costs and increased value of care.

Achieving Textbook Outcomes after Laparoscopic Resection in Posterosuperior Segments of the Liver: The Impact of the Learning Curve.

Achieving textbook outcomes (TOs) improves the short-term and long-term performance of a hospital. Our objective was to assess TOs in the laparoscopic liver resection (LLR) of tumors in the PS (posterosuperior) section of the liver and identify the impact of the learning curve. We conducted a retrospective cohort study analyzing patients who underwent LLR for lesions located in the PS segments. Patients were divided into a TO and no-TO group. TOs were defined as negative margins, no transfusion, no readmission, no major complications, no 30-day mortality, and a length of stay ≤ 50th percentile. Patients' outcomes were assessed in two study periods before and after 2015. TOs were achieved in 47.6% (n = 117). In multivariable analysis, obesity (p = 0.001), shorter operation time (p < 0.001), less blood loss (p < 0.001), normal albumin (p = 0.003), and minor resection (p = 0.046) were significantly associated with achieving TOs. Although the 5-year recurrence-free survival rate (p = 0.096) was not significantly different, the 5-year overall survival rate was significantly greater in the TO group (p = 0.001). Body mass index > 25 kg/m2 (p = 0.020), age > 65 years (p = 0.049), and achievement of TOs (p = 0.024) were independently associated with survival. The proportion of patients who achieved a TO was higher after 2015 than before 2015 (52.3% vs. 36.1%; p = 0.022). TOs are important markers not only for assessing hospital and surgeon performance but also as predictors of overall survival. As the number of surgeons who achieve the learning curve increases, the number of patients with TOs will gradually increase with a subsequent improvement in overall survival.