Academic Advancement in Global Surgery: Appointment, Promotion, and Tenure: Recommendations From the American Surgical Association Working Group on Global Surgery.

: There is growing interest in global surgery among US academic surgical departments. As academic global surgery is a relatively new field, departments may have minimal experience in evaluation of faculty contributions and how they integrate into the existing academic paradigm for promotion and tenure. The American Surgical Association Working Group on Global Surgery has developed recommendations for promotion and tenure in global surgery, highlighting criteria that: (1) would be similar to usual promotion and tenure criteria (eg, publications); (2) would likely be undervalued in current criteria (eg, training, administrative roles, or other activities that are conducted at low- and middle-income partner institutions and promote the partnerships upon which other global surgery activities depend); and (3) should not be considered (eg, mission trips or other clinical work, if not otherwise linked to funding, training, research, or building partnerships).

Cost and outcomes of open versus laparoscopic cholecystectomy in Mongolia.

Background: Laparoscopic cholecystectomy (LC) is the standard of care for biliary disease in developed countries. LC in resource-limited countries is increasing. This prospective, observational study evaluates costs, outcomes, and quality of life (QoL) associated with laparoscopic versus open cholecystectomy (OC) in Mongolia.

Outcomes and Costs for Major Lung Resection in the United States: Which Patients Benefit Most From High-Volume Referral?

Background: Accountable care organizations are designed to improve value by decreasing costs and maintaining quality. Strategies to maximize value are needed for high-risk surgery. We wanted to understand whether certain patient groups were differentially associated with better outcomes at high-volume hospitals in terms of quality and cost.

Readmission destination and risk of mortality after major surgery: an observational cohort study.

Background: Hospital readmissions are common after major surgery, although it is unknown whether patients achieve improved outcomes when they are readmitted to, and receive care at, the index hospital where their surgical procedure was done. We examined the association between readmission destination and mortality risk in the USA in Medicare beneficiaries after a range of common operations.

Methods: By use of claims data from Medicare beneficiaries in the USA between Jan 1, 2001, and Nov 15, 2011, we assessed patients who needed hospital readmission within 30 days after open abdominal aortic aneurysm repair, infrainguinal arterial bypass, aortobifemoral bypass, coronary artery bypass surgery, oesophagectomy, colectomy, pancreatectomy, cholecystectomy, ventral hernia repair, craniotomy, hip replacement, or knee replacement.

Measuring and Comparing the Cost-Effectiveness of Surgical Care Delivery in Low-Resource Settings: Cleft Lip and Palate as a Model.

Cleft lip and palate (CLP) care is the longest sustained global effort in humanitarian surgical care. However, the relative cost-effectiveness of surgical delivery approaches remains largely unknown. We assessed the cost-effectiveness of two strategies of CLP surgical care delivery in low resource settings: medical mission and comprehensive care center.

Training surgical residents for a career in academic global surgery: a novel training model.

Academic global surgery is a nascent field focused on improving surgical care in resource-poor settings through a broad-based scholarship agenda. Although there is increasing momentum to expand training opportunities in low-resource settings among academic surgical programs, most focus solely on establishing short-term elective rotations rather than fostering research or career development. Given the complex nature of surgical care delivery and programmatic capacity building in the resource-poor settings, many challenges remain before global surgery is accepted as an academic discipline and an established career path.

Hospital-level Variation in Secondary Complications After Surgery.

Objectives: To assess whether hospital rates of secondary complications could serve as a performance benchmark and examine associations with mortality.

Background: Failure to rescue (death after postoperative complication) is a challenging target for quality improvement. Secondary complications (complications after a first or "index" complication) are intermediate outcomes in the rescue process that may provide specific improvement targets and give us insight into how rescue fails.

Racial variation in the use of life-sustaining treatments among patients who die after major elective surgery.

Background: Although various studies have documented increased life-sustaining treatments among racial minorities in medical patients, whether similar disparities exist in surgical patients is unknown.

Methods: A retrospective cohort study using the Nationwide Inpatient Sample (2006 to 2011) examining patients older than 39 years who died after elective colectomy was performed. Primary predictor variable was race, and main outcome was the use of life-sustaining treatment.

Impact of sepsis on risk of postoperative arterial and venous thromboses: large prospective cohort study.

Objectives: To evaluate the impact of preoperative sepsis on risk of postoperative arterial and venous thromboses.

Design: Prospective cohort study using the National Surgical Quality Improvement Program database of the American College of Surgeons (ACS-NSQIP).

Setting: Inpatient and outpatient procedures in 374 hospitals of all types across the United States, 2005-12.

The combined risk of donor quality and recipient age: higher-quality kidneys may not always improve patient and graft survival.

Background: The Kidney Donor Profile Index (KDPI) is a more precise donor organ quality metric replacing age-based characterization of donor risk. Little prior attention has been paid on the outcomes of lower-quality kidneys transplanted into elderly recipients. Although we have previously shown that immunological risks associated with older organs are attenuated by advanced recipient age, it remains unknown whether risks associated with lower-quality KDPI organs are similarly reduced in older recipients.

Will there be a good general surgeon when you need one? (Part II) Solutions and taking back general surgery.

Introduction: Multiple reports have cited the looming shortage of physicians over the next decades related to increasing demand, an aging of the population, and a stagnant level in the production of new physicians. General surgery shares in this problem, and the specialty is "stressed" by a declining workforce related to increasing specialization that leaves gaps in emergency, trauma, and rural surgical care.

Summary: The Society of Surgery of the Alimentary Tract (SSAT) Public Policy and Advocacy Committee sponsored panel discussions regarding the general surgery workforce shortage at the Digestive Disease Week 2012 and 2013 meetings.

An efficient risk adjustment model to predict inpatient adverse events after surgery.

Background: Risk adjustment is an important component of surgical outcomes and quality analyses. Current models include numerous preoperative variables; however, the relative contribution of these variables may be limited. This research seeks to identify a model with the fewest number of variables necessary to perform an adequate risk adjustment to predict any inpatient adverse event for use in resource-limited settings.

A pilot comparison of standardized online surgical curricula for use in low- and middle-income countries.

Importance: Surgical conditions are an important component of global disease burden, due in part to critical shortages of adequately trained surgical providers in low- and middle-income countries.

Objectives: To assess the use of Internet-based educational platforms as a feasible approach to augmenting the education and training of surgical providers in these settings.

Design, Setting, And Participants: Access to two online curricula was offered to 75 surgical faculty and trainees from 12 low- and middle-income countries for 60 days.

Failure to rescue in safety-net hospitals: availability of hospital resources and differences in performance.

Importance: Failure to rescue (FTR), the mortality rate among surgical patients with complications, is an emerging quality indicator. Hospitals with a high safety-net burden, defined as the proportion of patients covered by Medicaid or uninsured, provide a disproportionate share of medical care to vulnerable populations. Given the financial strains on hospitals with a high safety-net burden, availability of clinical resources may have a role in outcome disparities.

Shortage of doctors, shortage of data: a review of the global surgery, obstetrics, and anesthesia workforce literature.

Introduction: The global surgery workforce is in crisis in many low- and middle-income countries (LMICs). The shortage of surgery, obstetrics, and anesthesia providers is an important cause of the unmet need for surgical care in LMICs. The goal of this paper is to summarize the available literature about surgical physicians in LMICs and to describe ongoing initiatives to supplement the existing surgical workforce data.

Preoperative hypernatremia predicts increased perioperative morbidity and mortality.

Background: The prognostic implications of preoperative hypernatremia are unknown. We sought to determine whether preoperative hypernatremia is a predictor of 30-day perioperative morbidity and mortality.

Methods: We conducted a cohort study using the American College of Surgeons-National Surgical Quality Improvement Program and identified 908,869 adult patients undergoing major surgery from approximately 300 hospitals from the years 2005 to 2010.

Carotid endarterectomy in asymptomatic patients with limited life expectancy.

Background And Purpose: Data from randomized trials assert that asymptomatic patients undergoing carotid endarterectomy (CEA) must live 3 to 5 years to realize the benefit of surgery. We examined how commonly CEA is performed among asymptomatic patients with limited life expectancy.

Methods: Within the American College of Surgeons National Quality Improvement Project we identified 8 conditions associated with limited life expectancy based on survival estimates using external sources.

Cost-effectiveness of preoperative nasal mupirocin treatment in preventing surgical site infection in patients undergoing total hip and knee arthroplasty: a cost-effectiveness analysis.

Objective: To perform a cost-effectiveness analysis to evaluate preoperative use of mupirocin in patients with total joint arthroplasty (TJA).

Design: Simple decision tree model.

Setting: Outpatient TJA clinical setting.

Adverse events do not outweigh benefits of combination therapy for Crohn's disease in a decision analytic model.

Background & Aims: The Study of Biologic and Immunomodulator-Naïve Patients With Crohn's Disease (SONIC) showed that combination therapy with infliximab and azathioprine (IFX/AZA) is more effective than treatment with IFX alone. Numbers and types of adverse events were roughly equivalent among groups, although enrollment was limited, so it was not clear how rare adverse events might affect overall outcomes in practice. We sought to define the frequency at which a rare adverse event would have to occur for the risks of combination therapy to outweigh the benefits of treatment.

Getting the science right on the surgeon workforce issue.

In this article we summarize the perspectives given by a range of health policy researchers as presented at the fifth annual meeting of the Surgical Outcomes Club at the annual meeting of the American College of Surgeons in Chicago, Illinois, on October 11, 2009. During that session, the participants reviewed 3 main areas that are summarized here: history of physician/surgeon workforce policy, current beliefs, recent policy activity, and issues related to forecasting/planning the future surgical workforce.

Small area variation in endoscopic sinus surgery rates among the Medicare population.

Objectives: To determine endoscopic sinus surgery (ESS) rates among 306 hospital referral regions (HRRs) and to assess whether variability in ESS rates correlates with population density of beneficiaries, per capita number of otolaryngologists within an HRR, or proportion of patients diagnosed as having chronic rhinosinusitis.

Design: Retrospective cohort analysis.

Setting: Academic research.

Perforated appendicitis among rural and urban patients: implications of access to care.

Objective: To determine whether rural patients are more likely to present with perforated appendicitis compared with urban patients.

Background: Appendiceal perforation has been associated with increased morbidity, length of hospital stay, and overall health care costs. Recent arguments suggest that high rates of appendiceal rupture may be unrelated to the quality of hospital care, and rather associated with inadequate access to surgical care.