Explore the vast range of titles available.

In this randomized trial comparing ACGME duty-hour policies with more flexible policies for surgical residents, the flexible policies resulted in noninferior patient outcomes and no significant difference in residents' satisfaction with overall well-being and education quality. In response to concerns about patient safety and resident well-being, the Accreditation Council for Graduate Medical Education (ACGME) introduced national regulations in 2003 that limited resident duty periods to 80 hours per week, capped overnight shift lengths, and mandated minimum time off between shifts. 1 , 2 Concerns persisted, 3 and in 2011, the ACGME implemented further restrictions to shorten maximum shift lengths for interns and increase time off after overnight on-call duty for residents. 1 , 4 , 5 Although most observers agree that some duty-hour regulation was necessary, critics cite a weak evidence base for the 2003 and 2011 reforms. 3 , 6 , 7 Several retrospective . . .

Introduction: Abdominal pain is the leading emergency department (ED) chief complaint in older (≥65 years of age) adults, accounting for 1.4 million ED visits annually. Ultrasound and computed tomography (CT) are high-yield tests that offer rapid and accurate diagnosis for the most clinically significant causes of abdominal pain. In this study we used nationally representative data to examine racial/ethnic differences in cross-sectional imaging for older adults presenting to the ED with abdominal pain. Methods: We performed a retrospective, cross-sectional analysis using data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) to assess differences in the rate of imaging between White and Black older adults presenting to the ED for abdominal pain. Our primary outcome was the receipt of abdominal CT and/or ultrasound imaging. Results: Across 1,656 older adult ED visits for abdominal pain, White patients were 26.8% (relatively, 14.2% absolute) more likely to receive abdominal CT and/or ultrasound than Black patients: 802 of 1,197 (67.0%) White patients were 26.8% (relatively, 14.2% absolute) more likely to receive abdominal computed tomography and/ or ultrasound than Black patients (P=0.01). Conclusion: This study revealed that Black older adults presenting to the ED with abdominal pain receive significantly lower levels of cross-sectional imaging (CT/ultrasound) than White patients. Our findings highlight the need for further investigations into causes of disparities while initiating quality improvement processes to assess and address site- and clinician-specific patterns of care.

ObjectivesEvaluate whether hospital factors, including nurse resources, explain racial differences in Medicare black and white patient surgical outcomes and whether disparities changed over time.DesignRetrospective tapered-match.Setting571 hospitals at two time points (Early Era 2003–2005; Recent Era 2013–2015).Participants6752 black patients and three sets of 6752 white controls selected from 107 001 potential controls (Early Era). 4964 black patients and three sets of 4964 white controls selected from 74 108 potential controls (Recent Era).InterventionsBlack patients were matched to white controls on demographics (age, sex, state and year of procedure), procedure (demographics variables plus 136 International Classification of Diseases (ICD)-9 principal procedure codes) and presentation (demographics and procedure variables plus 34 comorbidities, a mortality risk score, a propensity score for being black, emergency admission, transfer status, predicted procedure time).Outcomes30-day and 1-year mortality.ResultsBefore matching, black patients had more comorbidities, higher risk of mortality despite being younger and underwent procedures at different percentages than white patients. Whites in the demographics match had lower mortality at 30 days (5.6% vs 6.7% Early Era; 5.4% vs 5.7% Recent Era) and 1-year (15.5% vs 21.5% Early Era; 12.3% vs 15.9% Recent Era). Black–white 1-year mortality differences were equivalent after matching patients with respect to presentation, procedure and demographic factors. Black–white 30-day mortality differences were equivalent after matching on procedure and demographic factors. Racial disparities in outcomes remained unchanged between the two time periods spanning 10 years. All patients in hospitals with better nurse resources had lower odds of 30-day (OR 0.60, 95% CI 0.46 to 0.78, p<0.010) and 1-year mortality (OR 0.77, 95% CI 0.65 to 0.92, p<0.010) even after accounting for other hospital factors.ConclusionsSurvival disparities among black and white patients are largely explained by differences in demographic, procedure and presentation factors. Better nurse resources (eg, staffing, work environment) were associated with lower mortality for all patients.

Background The rate of lymph node (LN) metastasis is rare in soft tissue sarcoma, but there are histologic subtypes that metastasize via the lymphatics. The prognostic value of LN evaluation in these high-risk histologies is unknown. Methods Resected soft-tissue sarcoma patients with clear cell sarcoma, epithelioid sarcoma, rhabdomyosarcoma, or angiosarcoma ( n  = 2993) were identified in the National Cancer Data Base (2004–2013). Cox regression evaluated the association of omission of LN assessment (NX) and overall survival (OS). Subjects who underwent surgical resection with or without regional LN evaluation were matched (1:1) by propensity scores based on the likelihood of NX or survival hazard on Cox modeling. OS was compared by Kaplan–Meier estimates. Results A total of 637 (21.3%) underwent LN evaluation and 176 (5.9%) were found to have nodal metastasis. Omission of nodal evaluation was significantly associated with risk of death (reference: N0; N+: hazard ratio [HR] 1.46, 95% confidence interval [CI] 1.11–1.91; NX: OR 1.18, 95% CI 1.00–1.40). After propensity score matching, there was a significant difference in median OS following pathologic identification of nodal disease for epithelioid sarcoma (N0: not reached vs. N+: 55.9 months vs. NX: not reached, p  = 0.001) and clear cell sarcoma (N0: not reached vs. N+: 20.0 months vs. NX: 95.0 months, p  < 0.001). Conclusions These data support more standardized approaches to regional lymph node examination for patients with epithelioid and possibly clear cell sarcoma and provide compelling evidence that nodal evaluation can be considered a quality measure in the delivery of cancer care for certain sarcoma subtypes.

Marginalized communities are at risk of receiving inequitable access to surgical care. We aimed to examine the barriers and facilitators to access to surgery in underinsured and immigrant populations. A systematic review of disparities in access to surgical care was performed between January 1, 2000–March 2, 2022. Methodological quality was assessed with the Mixed Methods Appraisal Tool. A convergent integrated approach was used to code common themes between studies. Of 1315 publications, a total of 66 studies were included for systematic review. Eight studies specifically discussed immigrant patient populations. Barriers and facilitators to surgical access were categorized by patient and health systems related factors. Established facilitators to improve surgical access are centered on patient-level factors while interventions to address systems-related barriers are limited and may be an area for further investigation. Research focused on access to surgery in immigrant populations remains sparse. •Underinsured and immigrant patients are at risk of surgical access disparities.•Patient and systems-related factors contribute to barriers to surgical access.•Facilitators to surgical access include education, financial and social resources.

In 2016, Section 1557 mandated use of qualified language interpreter services. We examined the effect of Section 1557 on surgical outcomes. Utilizing the Healthcare Cost and Utilization Project State Inpatient Database (2013–2020), we performed a difference-in-differences analysis of adult surgical patients (Maryland, New Jersey). The exposure was implementation of Section 1557 (pre-period: 2013–2015; post-period: 2017–2020). The treatment group was non-English primary language speakers (n-EPL). The comparison group was English primary language speakers (EPL). Outcomes included length-of-stay, postoperative complications, mortality, discharge disposition, and readmissions. Among 2,298,584 patients, 198,385 (8.6%) were n-EPL. After implementation of Section 1557, n-EPL saw no difference in readmission rates but did experience significantly higher rates of mortality (+0.43%, p ​= ​0.049) and non-routine discharges (+1.81%, p ​= ​0.031) in Maryland, and higher rates of post-operative complications (+0.31%, p ​= ​0.001) in both states, compared to pre-Section 1557. Contrary to our hypothesis, Section 1557 did not improve surgical outcomes for n-EPL. •Section 1557 of the Affordable Care Act mandates qualified interpreter services.•Post Section 1557, n-EPL had no difference in readmission rates compared to EPL.•Post Section 1557, n-EPL experienced higher rates of mortality.•Post Section 1557, n-EPL had higher non-routine discharge and complication rates.

BACKGROUND:Instrumental variable (IV) methods are becoming an increasingly important tool in health services research as they can provide consistent estimates of causal effects in the presence of unobserved confounding. However, investigators must provide justifications that the IV is independent with any unmeasured confounder and its effect on the outcome occurs only through receipt of the exposure. These assumptions, while plausible in some contexts, cannot be verified from the data. METHODS:Falsification tests can be applied to provide evidence for the key IV assumptions. A falsification test cannot prove the assumptions hold, but can provide decisive evidence when the assumption fails. We provide a general overview of falsification tests for IV designs. We highlight a falsification test that utilizes a subpopulation of the data where an overwhelming proportion of units are treated or untreated. If the IV assumptions hold, we should find the intention-to-treat effect is zero within these subpopulations. RESULTS:We demonstrate the usage of falsification tests for IV designs using an IV known as tendency to operate from health services research. We show that the falsification test provides no evidence against the IV assumptions in this application.

Abstract Purpose Secondary hyperparathyroidism (SHPT) frequently affects patients with end-stage renal disease. Hungry bone syndrome (HBS) is a common complication among patients who undergo parathyroidectomy for SHPT and may cause prolonged hospitalization or require intensive care. The objective of this study is to develop a scoring system to stratify patients according to their risk of developing HBS. Methods A retrospective cohort study was performed using the US Renal Data System (2010-2021). Univariable and multivariable logistic regression models were developed and weighted β-coefficients from the multivariable model were used to construct a risk score for the development of HBS. Positive and negative predictive values were assessed. Results Of 17 074 patients who underwent parathyroidectomy for SHPT, 19.4% developed HBS. Intensive care unit admission was more common in patients who developed HBS (33.5% vs 24.6%, P < .001). On multivariable logistic regression analysis, younger age, renal osteodystrophy, longer duration of dialysis, longer duration of kidney transplant, and higher Elixhauser score were significantly associated with HBS. A risk score based on these clinical factors was developed, with a total of 6 possible points. Rates of HBS ranged from 8% in patients with 0 points to 44% in patients with 6 points. The risk score had a poor positive predictive value (20.3%) but excellent negative predictive value (89.3%) for HBS. Conclusion We developed a weighted risk score that effectively stratifies patients by risk for developing HBS after parathyroidectomy. This tool can be used to counsel patients and to identify patients who may not require postoperative hospitalization.