2023 Abstracts

Introduction: Effective teamwork and leadership skills are necessary for optimal patient care. The aim of this project was to assess the association between surgeons’ nontechnical skills and patient outcomes.

Methods: Operating room nurses, anesthesiologists, and trained observers assessed surgeons’ nontechnical skills using a validated instrument (NOTSS) at a single large urban academic hospital in the USA from February to August 2022. Patient outcome data were collected from the Illinois Surgical Quality Improvement Collaborative (ISQIC) database. We used the American College of Surgeons National Quality Improvement Program (ACS NSQIP) method to calculate the surgeon’s risk-adjusted complications. Linear regression models were used to assess the association between NOTSS score and risk-adjusted post-operative complications.

Results: Of the 45 surgeons who were observed in the study, 23 (51.1%) had patient outcome data captured by the ISQIC database. The median NOTSS score was 3.7, range [2.8 – 4]. For every unit increase in the NOTSS score, there was a significant 0.9 decrease in the adjusted risk of any post-operative complication [95% CI: -1.9; -0.06], a significant 1.6 decrease in the adjusted risk of returning to the operating room [95% CI: -3.2; - 0.08], and a significant 3.3 decrease in adjusted non-skills composite complication [95% CI: -5.8; -0.8].

Conclusion: Higher surgeons' non-technical skills were associated with the decreased risk-adjusted complication of any postoperative complication and returning to the operating room. Strategies to improve post-operative patient outcomes should include the improvement of surgeons' non-technical skills.

Introduction: Significant challenges exist in recruiting newly diagnosed patients with ductal carcinoma in situ (DCIS) to participate in presurgical intervention trials. Perceived motivators and barriers to participation have not been formally studied from the post-menopausal woman (PMW) or healthcare provider (HCP) perspective. To identify potential targets to improve DCIS clinical trial recruitment, we conducted focus groups with PMW, HCPs, and patients with a personal history of DCIS (HxDCIS).

Methods: Three focus groups of PMW without history of DCIS, one focus group of HxDCIS, and two HCP focus groups were conducted. The focus groups took place online via videoconferencing and included participants from across the United States. A third-party facilitator generated discussion on predetermined topics including knowledge of DCIS, clinical trial recruitment materials, hormone replacement therapy, healthcare delivery and clinical trials during COVID-19, and perceived motivators and barriers to trial participation in general and specifically for women with DCIS. Here, we focus on comparing perceived influential factors for patient participation in DCIS clinical trials in PMW and HCP focus groups. Qualitative thematic analysis was completed on focus group transcripts in NVivo.

Results: PMW had no knowledge of DCIS prior to the focus groups and believed DCIS should be removed promptly. PMW believed barriers to DCIS clinical trial participation included the potential for the study drug to cause harm, distrust of medicine, and the fact that DCIS is not life-threatening. PMW identified helping future DCIS patients, accessing better treatment, and easing anxiety as motivators for DCIS trial participation. HCPs believed patients were motivated by increased monitoring by the medical team, financial incentive, and access to newer treatment. HCPs believed that delays in DCIS surgery, the potential for the intervention to be harmful or ineffective, and the trial causing patient anxiety were barriers. Neither group emphasized time commitment as a barrier to DCIS trial participation. PMW were not motivated by financial incentives.

Conclusion: Knowledge about DCIS is lacking in PMW. PMW and HCPs agreed that the risk of harm caused by study interventions is a deterrent to trial participation and that access to superior treatment is a motivator. However, PMW and HCPs did not agree on other motivators and barriers which could lead to missed recruitment opportunities. Providing educational materials on DCIS and addressing motivators and barriers to clinical trial participation may increase recruitment to presurgical DCIS trials.

Introduction: Disparate breast cancer outcomes have been reported in urban versus rural settings and for low-income patients. To our knowledge, the interaction between rurality and income in breast cancer outcomes has not yet been explored.

Methods: The NCI’s SEER 17 Registry was queried for new breast cancer diagnoses from 2000-2020. Analysis was performed with SEER*Stat version 8.4.1. Location was defined according to SEER’s Rural-Urban Continuum Code(RUCC), with urban=0-3 and rural=4-9. Annual income was defined as <$35K, $35-50K, $50-75K, and >$75K. Data was stratified by rurality and income level.

Results: 936,629 breast cancer cases were identified, of which 836,708(89.3%) were urban and 99,921(10.7%) were rural. In urban settings, significantly more white and Asian patients made>$75K, black patients made<$35K, and Hispanic patients made$50-75K(P<0.01). In rural settings, black and Hispanic patients were more likely to make<$50K compared to white and Asian patients(P<0.01). Across all incomes in both settings, the majority of patients were diagnosed<60 years. In urban settings, the proportion diagnosed<60 increased significantly with income(36.1% vs 45.4%,P<0.01). No significant differences in rates of male breast cancer in urban or rural settings across incomes(<1%,P=0.07 and 0.21). Majority of diagnoses were localized breast cancer(59.6-68.6%). Rates of regional and distant disease were significantly higher in incomes<$35K in urban(31.3% regional, 7.2% distant,P<0.01) and rural settings(32.9% regional, 7.5% distant,P<0.01). The majority of cases were HR+/Her2-(47%). Compared to >$75K, significantly more patients with income<$35K had TNBC in urban(10.8% vs 6.1%,P<0.01) and rural(9.5% vs 5.6%,P<0.01) settings. Significantly higher rates of TPBC was seen in incomes <$50K in urban(8.1% vs 6.7%,P<0.01) and rural settings(7.0% vs 5.9%,P<0.01). Significantly more<$35K patients were treated at 0 months in urban(40.9%,P<0.01) and rural settings(40.2%,P<0.01) compared to higher income patients. The majority of patients were treated within 3 months of diagnosis(97% urban, 98.5% rural). 5-year overall survival, relative survival, and disease-specific survival were significantly lower in<$35K vs >$75K in urban(74.4% vs 85.5%;88.4% vs 92.1%;83.4% vs 90.8%,P<0.05) and rural settings(75.6% vs 84.9%;84.6% vs 91.3%;84.0% vs 90.5%,P<0.05).

Conclusion: Racial disparities in income levels are present among breast cancer patients in urban and rural settings. Lower-income patients in both settings were less likely to be diagnosed<60 years, more likely to have regional or distant disease, an aggressive subtype, and be treated at<1mo. Overall, relative, and disease-specific survival were significantly lower in<$35K incomes in both settings. The complex interaction between rurality and income in terms of breast cancer outcomes still needs to be elucidated, but disparities exist at the population level.

Introduction: Low preoperative hematocrit has been linked in numerous surgical disciplines to adverse postoperative outcomes. Cubital tunnel syndrome comprises the second most frequent peripheral neuropathy and understanding drivers of complications is necessary for prevention. Therefore, the present study aims to analyze the impact of preoperative hematocrit on short-term ulnar nerve decompression outcomes.

Methods: Ulnar nerve decompression surgeries (CPT 64718) were queried from the American College of Surgeons National Quality Improvement Program (NSQIP) database from 2005-2020. The primary variables of interest were preoperative serum hematocrit values, taken within 90 days. Additional covariates spanned preoperative and operative characteristics for each case. Outcomes of interest included return to operating room, non-home discharge, extended postoperative LOS (defined by the 75th percentile value in our cohort), medical complications, and wound complications. Per NSQIP, outcomes were reported within 30 days postoperatively. Cases missing data for any variables of interest, or cases that expired in hospital or left against medical advice, were excluded.

Bivariate analyses, conducted using t-tests, followed by a multivariate logistic regression were used to assess the predictive value. Any outcomes with demonstrated significance on both tests were finally analyzed using the J-Index and an Area Under the Receiver Operating Characteristic Curve. Clinical predictive cutoff points were derived separately for males and females since hematocrit reference ranges are sex-specific.

Results: A total of 945 patients were analyzed in our cohort (Average Age: 56.0 years, Males: 52.5%, Average Hematocrit: 40.57%). Upon bivariate analysis, patients who experienced return to the operating room, non-home discharge, medical complications, and increased LOS had significantly decreased hematocrit levels (p<0.05). Multivariate logistic regression revealed that increases in hematocrit significantly decreased the odds of return to the operating room (aOR: 0.899, p=0.025), medical complications (aOR: 0.871, p=0.003), and increased LOS (aOR: 0.952, p=0.048). Among female patients, predictive hematocrit cutoff values of ≤ 38.1% (AUC: 0.59, p=0.013) for extended length of stay and ≤ 35.4% for medical complications (AUC: 0.77, p<0.001) were identified. Among male patients, hematocrit lab values of ≤ 39.2% (AUC: 0.68, p<0.001) for extended length of stay, ≤ 40.9% (AUC: 0.68, p=0.018) for return to operating room, and ≤ 38.1% (AUC: 0.72, p=0.012) for medical complications were identified.

Conclusions: Patients with low hematocrit experienced increased postoperative morbidity after ulnar decompression. These findings can help inform patient-provider discussions preoperatively and aid in optimal timing of surgical intervention.

Introduction: Venous thromboembolism (VTE) is a common cause of perioperative morbidity and mortality after surgical treatment of lung cancer. VTE chemoprophylaxis has been shown to reduce the incidence of VTE, and recent guidelines have been established for extended post-discharge chemoprophylaxis for patients with resected lung cancer. However, specific risk factors associated with VTE are unknown.

Methods: The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) was used to identify patients who underwent anatomic lung resection between 2015 and 2018. Bivariate analysis and multivariable logistic regression were used to identify post-discharge VTE risk factors which were used to create a post-discharge VTE risk calculator.

Results: The study included 18,476 patients who underwent anatomic lung resection. Overall, VTE was diagnosed within 30 days of surgery in 224 (1.2%) patients with 203 (1.1%) diagnosed in-patient and 21 (0.11%) diagnosed post-discharge. Older age, male sex, non-Hispanic Black race, higher body mass index (BMI), longer operative time, longer post-operative length-of-stay, transfusion, myocardial infarction, chronic obstructive pulmonary disease, post-operative pneumonia, mechanical ventilation >48hrs, renal failure, and open pneumonectomy were identified as risk factors for overall risk of VTE. Post-discharge VTE was associated with BMI (odds ratio 1.06, 95% confidence interval 1.03-1.10 per point increase), open pneumonectomy (odds ratio 4.62, 95% confidence interval 1.28-16.7), and post-operative pneumonia (odds ratio 14.3, 95% confidence interval 5.87-34.8). Twenty iterations of 10-fold cross-validation yielded a mean C-statistic of 0.84 indicating good model discrimination for post-discharge VTE risk calculation. Predicted risk of post-discharge VTE after anatomic lung resection ranged from 0.02% to 8.95%.

Conclusions: VTE is an uncommon but potentially devastating complication after anatomic lung resection. Post-discharge VTE risk was associated with increasing patient BMI, open pneumonectomy, and post-operative pneumonia. Identifying patients at high risk for post-discharge VTE may help guide patient specific extended VTE chemoprophylaxis prescribing.

Introduction: Post-operative neuromas are an under-recognized contributor to chronic abdominal pain. Surgical management of painful abdominal wall neuromas has not been well reported in the literature, and no gold standard of care exists. We present a review of patient reported outcomes following surgical treatment of painful abdominal wall neuromas using established techniques for management of painful neuromas in the upper and lower extremity. This is the first study of the efficacy of TMR for abdominal wall neuromas.

Methods: After Institutional Review Board approval, a retrospective review was performed of all patients who underwent surgical treatment for painful abdominal wall neuromas by the senior author at Northwestern Memorial Hospital (2009-2020). Patients were treated with neuroma excision and allograft nerve reconstruction and/or with Targeted Muscle Reinnervation (TMR). Follow-up pain surveys were issued to assess pain levels, activities of daily living, and pain medication usage.

Results: Twenty patients met inclusion criteria. Ninety percent (18) of patients reported improvement in neuropathic pain postoperatively. Ten percent (2) of patients had TMR following failed nerve allograft reconstruction, which led to complete pain resolution. Twenty-seven nerves were treated surgically, the majority (48%, 13) were abdominal intercostal nerves, followed by ilioinguinal (37%, 10), genitofemoral (11%, 3) and iliohypogastric (4%, 1). Nerve allograft reconstruction was used alone for 18 procedures, in combination with TMR for two, and TMR was used alone in eight procedures. In all cases of TMR, the freshened nerve ending after neuroma excision was coapted to a local motor nerve of the internal oblique. The survey was completed by 75% (15) of the study patients. The mean level of abdominal pain over the past week the survey was taken was 2.8 (SD ±2.3), on a 0–10 scale with 0 being no pain and 10 being severe pain, and the respondents’ mean level of emotional upset (including depression and anxiety symptoms) was 2.4 (SD ±2.2). The mean length of follow up for all patients was 18.9 months (SD±14.5).

Conclusions: This retrospective review demonstrated 90% (18) of patients had significant improvement in chronic abdominal neuroma pain following surgical treatment with nerve allograft reconstruction and/or TMR. These results may help guide providers towards effective, management of abdominal wall neuropathic pain.

Introduction: Analysis of patient experience survey data has historically focused on doctor-patient communication, staff responsiveness, quality of explanations, and overall perception of the healthcare experience. This study examines the relationship between language-discordant care and patient experience ratings.

Methods: Retrospective review of de-identified pediatric plastic surgery patient experience survey responses from August 2021- July 2022 was performed with permission from Lurie Children’s Hospital’s Patient Family Experience Team. IBM® SPSS Statistics was used for statistical analysis.

Results: 443 pediatric plastic surgery patients were included. Racial/ethnic distributions were White (49%), Other (23.9%), Black (8.8%), Asian (5.9%), with Not Hispanic/Latino (58.2%) and Hispanic/Latino (31.4%). Languages spoken were English (80.4%), Spanish (18.1%) and Other (2.3%). 87 (19.64%) patients were language-discordant with their providers based on their and providers’ spoken language(s); out of this group, 68 (78.2%) preferred interpreter services. Interpreter services methods included in-person (54.4%), over-the-phone (27.9%), video (1.5%), and none (16.2%). Compared with language-concordant group, language-discordant group was less likely to give highest rankings to “provider courtesy and respect” (OR=0.20, 95% CI=0.092-0.432, p<0.001), “provider listened carefully” (OR=0.202, 95% CI=0.095-0.428, p<0.001), and “knowing what to do with subsequent questions following visit” (OR=0.435, 95% CI=0.322-1.267, p=0.007). No differences in patient experience survey scores existed between patient/provider language-discordant vs. concordant groups for: “enough information provided” (p=0.522), overall provider rating (p=0.073), and recommending facility (p=0.565). There were no significant differences in provider ratings by interpreter service method (p=0.593).

Conclusions: Patient/provider language discordance negatively affected patient experience ratings in areas involving patient teaching and perception of provider’s respect, courtesy, and careful listening. Language discordance did not affect overall provider and facility ratings.

Introduction: Across scar studies, there is a lack of dark-skinned individuals, who have a predisposition for keloid formation, altered pigmentation, and poorer quality-of-life. There is a need for patients-of-color to be included in scar scale development and validation. In this study, we evaluate the racial diversity of patients included in the validation of scar assessment scales.

Methods: A systematic review was conducted for articles reporting on the validation of a scar assessment tool. Racial, ethnic, and Fitzpatrick skin type(FST) data was extracted.

Results: Fifteen scar scale validation studies were included. Nine of the studies did not mention FST, race, or ethnicity of the patients. Two of the studies that reported FST or race information only included White patients or included no FST V/VI patients: MAPS and UNC4P. Only four studies included non-white patients or dark-skinned patients in the validation of their scar scale: the modified Vancouver Scar Scale, Modified POSAS, Acne QOL, and SCAR-Q scales. The patients included in the modified VSS validation were 7 and 13% FST V/VI, 14% African in the modified POSAS, and 4.5% FST V/VI in the SCAR-Q.

Conclusion: We highlight the severe lack of diversity in scar scale validation, with only 4 out of 15 studies including dark-skinned patients. Given the susceptibility of darker-skinned individuals to have poorer scarring outcomes, it is critical to include patients-of-color in the very assessment tools that determine their scar prognosis. Inclusion of patients-of-color in scar scale development will improve scar assessment and clinical decision-making.

Introduction: Social determinants of health (SDOH) have emerged as important risk factors of clinical outcomes, but little is known on their effects in patients with cirrhosis and those receiving a liver transplantation. We performed a population-based study in a large metropolitan area.

Methods: Using a multi-institution, electronic health record database in the Chicago metropolitan area, a retrospective analysis of adult patients (>17-years-old) with cirrhosis was performed from 2006-2012. SDOH factors were defined by the Area Deprivation Index (ADI) – a validated, publicly available, 17-item aggregate score that ranks community zip code-level socioeconomic status. Specific covariates that make up the ADI were also abstracted from the US Census Bureau’s American Census Survey. Higher ADI scores denote more deprived areas. Competing risk, multivariable analyses, and restricted mean survival time (RMST) analyses to predict all-cause mortality and transplant waitlist were adjusted for demographics, cirrhosis etiology, comorbidities, and severity of liver disease.

Results: Among 15,101 patients with cirrhosis, the mean (±SD) age was 57.16 (±11.66) years; 42.47% were women, 43.63% were Non-Hispanic White, 24.18% Black, and 50.98% enrolled in Medicare/Medicaid. ADI quintile was significantly associated with age, sex, race, insurance type, MELD-Na, mortality, and waitlist (p<0.001). Multivariable analysis shows that patients in the highest ADI quintile had an increased risk of all-cause mortality (HR 1.09, 95% CI 1.06-1.12, p<0.001) and lower risk of waitlist (HR 0.72, 95% CI 0.67-0.76, p<0.001), compared to those in the lowest ADI quintile. Neighborhood-level poverty, income disparity, unemployment, education, poor access to transportation, and clustered household composition were specific SDOH with the largest effect on likelihood of waitlisting (p<0.001). Compared to the lowest ADI quintile, patients in the highest ADI quintile were associated with decreased lifespan by 4.8 months (p<0.01) and delayed time to waitlist by 7.6 months (p<0.001) over 5-year follow-up on RMST analyses.

Conclusion: Patients with cirrhosis living in the most deprived neighborhoods had lower odds of survival and transplant waitlisting. Future research investigating public health interventions to address specific SDOH such as neighborhood-level poverty, income disparity, unemployment, education, access to transportation, and household composition are vital to mitigate disparities among disadvantaged neighborhoods.

Introduction: Neoadjuvant chemoimmunotherapy (NCI) is becoming more common for patients with stage IB to stage IIIA non-small-cell-lung cancer (NSCLC). However, optimal surgical management of cN2 disease which responds to NCI is unclear, specifically whether parenchymal-sparing resections would be as safe and appropriate as lobectomy. We hypothesized that patients with NCI-associated pathological downstaging will have comparable long-term survival to stage-matched patients who did not require neoadjuvant therapies.

Methods: The National Cancer Database was used to identify patients with surgically treated NSCLC between 2004-2018. Rates of NCI and neoadjuvant chemotherapy (NC) were compared. Odds of pathological complete response (pCR) were evaluated with multivariable regression. Overall survival (OS) was examined with Cox models. Kaplan-Meier curves were used to evaluate pT-stage stratified outcomes.

Results: Overall, 358,276 patients were included. Of 2,597 (0.7% of total cohort) patients with clinical stage IIIA (cN2) disease who received systemic neoadjuvant therapies, 60 (2.3%) received NCI and 2,537 (97.7%) received NC. NCI was associated with shorter intervals to surgery compared to NC (median 127 versus 137 days; p=0.02), higher rates of pCR (13.3% NCI vs 4.8% NC; p=0.003) (aOR 3.23, 95% CI 1.48-7.00), and improved OS (aHR 0.64, 95% CI 0.41-0.99 versus NC). Patients with clinical stage IIIA (cN2) disease downstaged to ≤pT1aN0M0 after NCI and lobectomy (n=20) had 30-month OS comparable to ≤pT1aN0M0 patients treated with lobectomy or segmentectomy without neoadjuvant therapies (log-rank p=0.87 and p=0.91, respectively).

Conclusions: NCI is associated with increased odds of pCR and improved OS. Patients downstaged to ≤pT1aN0M0 after NCI and lobectomy for stage IIIA (cN2) NSCLC may have similar OS compared to ≤pT1aN0M0 patients treated with lobectomy or segmentectomy.

Introduction: Over the past two decades, the use of neoadjuvant chemotherapy (NAC) and chemoradiation (NCR) have demonstrated improved survival for patients with gastric cancer compared to surgery alone. However, the optimal treatment remains unclear as randomized controlled trials directly comparing these strategies have yet to be completed. Our objective was to evaluate the association of different neoadjuvant treatment modalities with oncologic and survival outcomes among patients with gastric cancer.

Methods: The National Cancer Database was queried for patients who received NAC or NCR followed by resection for T2-T4 and/or node positive gastric adenocarcinoma from 2010-2019. Multivariable logistic regression assessed complete pathologic response (pCR), margin status, and lymph node ratio (LNR). Kaplan Meier methods and cox proportional hazards regression assessed overall survival (OS). All models were adjusted by propensity score and clustered by facility.

Results: Of 9,906 analyzed patients, 4,204 (42.4%) received NAC and 5,702 (57.6%) NCR. Patients who received NCR were more likely to have pCR (OR 1.74, 95%CI 1.44-2.10), margin-negative resection (OR 1.76, 95%CI 1.43-2.18), and a lower LNR (OR 1.47, 95%CI 1.29-1.69), when compared to those who received NAC. Median OS was 39.5 months for NAC and 35.3 months for NCR (p<0.001). On multivariable analysis, NCR independently predicted worse OS (vs NAC HR 1.18, 95%CI 1.12-1.25).

Conclusion: In this head-to-head comparison, NCR was associated with better tumor response when assessed histologically. However, this did not confer a survival benefit as NAC was associated with improved OS. These data highlight the need for randomized controlled trials directly comparing neoadjuvant treatments among this population.

Introduction: Survivors of intentional interpersonal violence face social challenges related to social determinants of health that led to their initial injury. Hospital-based violence intervention programs (HVIPs) reduce reinjury. It is unclear how well they meet clients’ reported needs. This systematic review aimed to quantify how well HVIP services addressed clients’ reported needs.

Methods: Medline, The Cochrane Library, CINAHL Plus with Full Text, and PsycInfo were queried for studies addressing HVIP services and intentional injury survivors’ needs in the United States. Case reports, reviews, editorials, theses, and studies focusing on pediatric patients, victims of intimate partner violence, or sexual assault were excluded. Data extracted included program structure, HVIP services, and client needs assessments before and after receiving HVIP services.

Results: Of the 3339 citations identified, 13 articles were selected for inclusion. HVIP clients’ most reported needs included mental health (10 studies), employment (7), and education (5) before receiving HVIP services. Only four studies conducted quantitative client needs assessments before and after receiving HVIP services. All four studies were able to meet at least 50% of each of the clients reported needs. The success rate depended on the need and program location: success in meeting mental health needs ranged from 65% to 90% of clients. Conversely, time intensive long-term needs were least met including employment 60-86% of clients, education 47-73% and housing 50%-71%.

Conclusion: Few HVIP studies considered clients’ reported needs. Employment, education and housing must be a stronger focus of HVIP services.

Introduction: There is evidence of delays in diagnosis of appendicitis, particularly among non-Hispanic Black patients. However, the economic burden of delays in diagnosis has not been quantified.

Methods: This was a retrospective cohort study using data from the Healthcare Cost and Utilization Project’s inpatient and emergency department (ED) databases for patients aged 18 to 64 who underwent appendectomy from 2016 to 2017. The primary outcome was total hospital cost of care calculated by applying cost-to-charge ratios to aggregated charges from any ED visits 7 days prior to and 30 days following appendectomy, after adjusting for wage index, inflation, and winsorization of outliers. The primary predictor was delay in diagnosis, defined as having a previous ED visit within 7 days pre-operatively with a diagnosis other than appendicitis and no surgery initially. A multivariable Poisson regression model was used to quantify the cost associated with delayed diagnosis.

Results: There were 77,074 patients who received an appendectomy, of which 2,057 (2.7%) were identified as having delayed diagnosis. The cohort was 51.1% female, 17.9% aged 55-64, and 10.8% non-Hispanic Black. Delayed diagnosis had a median cost of $11,093 compared to $9,186 for non-delayed diagnosis (p<0.001). Patients with delayed diagnosis had a 1.22 (95% CI, 1.16-1.28) times adjusted increased cost. Non-Hispanic Black patients had a 1.25 (95% CI, 1.20-1.30) times adjusted increased cost compared with non-Hispanic White patients after controlling for delayed diagnosis.

Conclusion: Patients with delayed diagnosis of appendicitis have significantly increased cost of care. Addressing these delays may help reduce healthcare spending.

Introduction: Surgical resection is the primary curative treatment for localized gastric cancer. A multitude of research supports surgical nodal sampling guidelines. Though there are known disparities in adherence to nodal sampling, it is unclear how hospital program-level disparities have changed over time. The purpose of this study is to evaluate trends in program-level disparities in adherence to gastric cancer nodal sampling guidelines.

Methods: Patients who underwent resection of gastric cancer from 2005-2017 were identified in the National Cancer Database (NCDB). Patients treated at academic programs were compared to those treated at nonacademic programs, and rates and trends of adherence to nodal sampling guidelines (defined as ≥15 lymph nodes) were determined. Adjusted multivariable analysis was used to determine likelihood of nodal sampling adherence and receipt of adjuvant chemotherapy while controlling for sociodemographic, clinical, hospital, and travel distance characteristics.

Results: A total of 55,421 patients were included with 27,201 (49.1%) of patients meeting adherence criteria for lymph node sampling. Academic programs treated 44.4% of the total cohort. Overall, lymph node sampling criteria were met in 59.2% of patients treated at high-volume academic programs and 37.0% of patients treated at low-volume nonacademic programs (IRR 0.67, 95% CI 0.63-0.72 vs high-volume academic programs). Adherence rates improved from 2005 to 2017 for both low-volume nonacademic programs (27.8% in 2005 to 50.1% in 2017) and high-volume academic programs (46.0% in 2005 to 69.8% in 2017, p<0.001). In adjusted multivariable analysis, lymph node guideline adherence (≥15 lymph nodes sampled) was associated with increased likelihood of receipt of adjuvant chemotherapy (IRR 1.23, 95% CI 1.20-1.27 vs <15 lymph nodes sampled).

Conclusion: Though adherence rates have improved from 2005-2017, nonacademic and low volume facilities have lower likelihood of successful adherence to guidelines for gastric cancer. Adherence to lymph node sampling guidelines is associated with increased likelihood of receipt of adjuvant therapy.

Introduction: With advances in current therapies, more patients are currently surgical candidates for oncologic resections that were previously deemed unresectable due to vascular invasion. We analyzed our institution’s outcomes of patients undergoing oncovascular resection of truncal malignancies with vascular invasion to identify factors associated with vascular reconstruction complications and oncologic recurrence.

Methods: A retrospective chart review of all adult patients between January 1, 2002 and June 1, 2022 who underwent a surgical resection of a neoplasm at Northwestern Memorial Hospital and required vascular surgery intraoperative assistance was performed. Data on patient demographics, tumor anatomy and pathology, operative details, and clinical outcomes was extracted. Primary endpoints included 30-day and 1-year mortality, and 1-year primary patency of the vascular reconstruction. Secondary endpoints included vascular reintervention and tumor recurrence, both local and metastatic disease.

Results: A total of 104 patients (43.3% females) with a mean age of 58 years were included in the study. Median follow up was 22.1 months (range 0-207). The most common tumor pathology included advanced renal cell carcinoma (n=58) and soft tissue and primary vascular sarcomas (n=24). Vascular procedures included 98 venous interventions and 6 arterial interventions. Overall 30-day mortality was 1% and 1-year mortality was 14.4%. Primary vascular patency at 1 year among patients with at least 12 months of follow up was 98.5%. No patients underwent a vascular reintervention. In total, 34 (38%) patients developed recurrent malignant disease (23.5% local and 76.5% metastatic) during the study period. Median time to tumor recurrence was 11.4 months (range 1.2-100).

Conclusions: Oncovascular resections of truncal tumors involving major vascular structures can be safely performed with a low incidence of vascular complications, while tumor recurrence remains the major contributor to morbidity. Further investigation of factors associated with tumor recurrence in these patients may help refine surgical techniques.

Introduction: Contralateral prophylactic mastectomy (CPM) is the removal of the healthy breast in women diagnosed with unilateral breast cancer. This procedure is being performed with increasing frequency in the United States in women without a genetic predisposition even though it is not associated with a survival advantage. For the average woman, the risk of a new contralateral breast cancer is about 0.4% per year, yet women overestimate this risk by 5-6-fold. In addition to reducing their perceived risk, women report choosing a CPM to provide peace of mind, reduce anxiety over continued screening, improve symmetry, and on the advice of family and friends. CPM should be discouraged for the average risk woman. Postoperative complications such as skin necrosis, autologous flap loss, and infected implants may delay adjuvant therapy and increase the risk for recurrence. Following CPM, a significant number of patients report chronic pain, poor cosmetic outcomes, and sexual dysfunction. The reasons behind this increasing trend are multifactorial but a major component could be due to inadequate and inconsistent patient counseling during surgical consultation. Goals: 1) Develop educational materials about the risks and benefits of CPM 2) Assess the rate of CPM at Lynn Sage Comprehensive Breast Center after providing patients with educational materials at the initial consultation and compare this rate to historical controls. It is hypothesized that patients will be able to make a more informed and thoughtful decision about their breast surgery, thus decreasing the rates of CPM.

Methods: Prospective Clinical Trial Design: This is a prospective cohort study to determine whether there is a statistically significant difference between the CPM rates before and after providing educational materials about the risks and benefits of CPM. Eligibility Criteria: All newly diagnosed women with breast cancer will be provided the educational materials. Patients with a significant family history or known genetic predisposition, and patients recurrent, metastatic, or inflammatory breast cancers will be excluded from the analysis. Specific Aims: To reduce in the CPM rate at Lynn Sage Breast Comprehensive Breast Center. Statistical Methods: Receipt of CPM is the primary dependent variable for analysis and will be measured according to a review of electronic medical record over the course of 2 consecutive years. A Wilcoxon signed rank test will be used to analyze the data. Present and Planned Accrual: 300 retrospective and 300 prospective

Introduction: Significant advances in technology and technique have facilitated minimally invasive repair of complex aortic aneurysms using fenestrated and branched endovascular devices(F/B-EVAR). We examined patient-reported quality of life (QOL) following F/B-EVAR using a survey instrument validated for aortic aneurysm repair.

Methods: A prospectively maintained database was used to identify and contact living patients that underwent F/B-EVAR for pararenal or thoracoabdominal aortic aneurysms at two institutions. Eligible patients (n=285) were asked to complete a QOL survey previously validated in patients that underwent open (OAR) or endovascular (EVAR) repair of an infrarenal abdominal aortic aneurysm. An emotional impact score (EIS) from 0-100 was derived from the survey with higher scores indicating more adverse emotional impact and worse QOL. Respondent activity change following F/B-EVAR was evaluated in four domains associated with aneurysmal disease.

Results: A total of 234 patients (82%) completed surveys. Mean post-operative interval to survey completion was 3.4(+/-2.8) years. Mean EIS for all patients surveyed was 16(+/-16) with minimally better EIS for patients more than one-year post-F/B-EVAR (20 vs 14). EIS is similar after F/B-EVAR when compared to prior results in patients after infrarenal OAR and EVAR. Within the EIS range (0-91) for this cohort, most respondents demonstrated limited adverse emotional impact after F/B-EVAR. However, the 4th quartile of EIS was broad (22-91) indicating a small portion of respondents had significantly worse QOL after F/B-EVAR. While patients most commonly reported no change after F/B-EVAR in each of the activity domains, over 40% of patients did report decrease in strenuous activity and heavy lifting after F/B-EVAR.

Conclusions: Patients undergoing F/B-EVAR demonstrate similar emotional QOL compared to EVAR, and slightly better emotional QOL compared to OAR in the first year. Patients most commonly report unchanged or decreased activity after F/B-EVAR. With confirmed feasibility of this disease-specific QOL instrument, its use in prospective evaluation of patients with complex aortic disease may provide greater insights into the impact of F/B-EVAR on QOL.

Introduction: Regionalization of care is associated with improved perioperative outcomes after adrenalectomy but may lead to increased travel distance for patients. However, the relationship between travel distance and treatment of adrenocortical carcinoma (ACC) is unknown. Our objective is to investigate the association between travel distance, treatment, and overall survival (OS) among patients with ACC.

Methods: Patients diagnosed with ACC between 2004-2017 were identified with the National Cancer Database. Long distance was defined as the highest quintile of patient travel (>42.2 miles). Likelihood of surgical versus non-surgical management (chemotherapy, chemoradiation, radiotherapy, or observation) and receipt of adjuvant chemotherapy were determined. The association between travel distance, treatment, and OS was evaluated.

Results: Of 3,492 patients with ACC included, 2,337 (66.9%) had surgery and 1,155 (33.1%) had non-surgical management. Rural residents were more likely to travel long distances for surgical treatment than metropolitan residents (63.6% versus 15.5%, p<0.001). Median travel distance for surgical treatment was higher for rural versus metropolitan residents (54.5, IQR 33.5-87.0 versus 11.0, IQR 5.2-26.1 miles; p<0.001). Among patients treated near their home (<4.4 miles), rural residents were less likely to receive surgery than metropolitan residents (IRR 0.35, 95% CI 0.13-0.96). In covariate adjusted models, surgery was associated with improved OS versus non-surgical management (HR 0.50, 95% CI 0.45-0.55). Among surgically treated patients, long- distance travel was associated with worse OS (HR 1.21, 95% CI 1.05-1.40. Overall, 807 (23.1%) patients received adjuvant chemotherapy with rates decreasing approximately 1% for every 4-mile increase in travel distance. For rural residents who travel long-distance, surgery was associated with superior OS (HR 0.67, 95% CI 0.48-0.92) versus rural residents who received non-surgical management. However, among rural surgically treated patients, long-distance travel had worse OS (HR 1.64, 95% CI 1.12-2.41 versus short-distance travel).

Conclusions: Surgery was associated with improved OS compared to non-surgical management, but only 17.6% of rural residents who sought care close to home were treated surgically. 63.6% of rural residents treated surgically traveled greater than 42.2 miles for care. Unfortunately, among those treated surgically, increased travel distance was associated with decreased overall survival and lower likelihood of receipt of adjuvant therapies. Continued efforts to understand the reasons for rural and travel distance disparities in access to oncological services and patient survival may yield targets for future improvement initiatives.

Introduction: Hispanic patients with cirrhosis have decreased mortality risk compared to Non-Hispanic White or Black patients. The effect of community level social vulnerability as a mediator of mortality among Hispanic patients with cirrhosis is unknown.

Methods: We conducted a retrospective cohort study of adult patients with cirrhosis from 6 health systems in a large metropolitan area from 2006-2012. The Social Vulnerability Index (SVI) [0=least, 1=most vulnerable] were used as a surrogate for community-level socioeconomic status. All-cause mortality and transplant risk were estimated by a Fine-Gray sub-distribution hazard model adjusting for covariates. Results: Of 19,939 patients with cirrhosis, mean age was 57.1 (SD±11yrs) and follow-up 2.6 (SD±0.7yrs). 8487 (43%) were female, 9055 (45%) were Non-Hispanic White (NHW), 4402 (22%) were Non-Hispanic Black (NHB), 3259 (16%) were Hispanic, 521 (3%) were Asian, and 2702 (14%) were Other. 6810 (34%) had private insurance, 9966 (50%) Medicare/Medicaid, and 3163 (16%) Other insurance. The most vulnerable quintile of ZIP-codes had more Hispanic (28%) and Black (47%) patients, and HCV (48%) and ETOH cirrhosis (43%) etiologies (p<0.01). In adjusted analysis, Hispanic patients overall had 13% decreased mortality risk (sHR=0.87, CI: 0.77-0.99, p<0.05), NHB patients had 47% increased mortality risk (sHR=1.47, CI:1.31-1.64, p<0.001), and Asian patients had no significantly different mortality risk compared to NHW patients. In an interaction analysis between SVI and race/ethnicity, Hispanic patients’ mortality risk decreased 15% per quintile increase in SVI (sHR = 0.85, CI: 0.77-0.94, p<0.05) compared to NWH patients. Mortality risk increased with SVI at similar rates for Black and Asian patients compared to White patients (Figure).

Conclusion: Compared to all other races and ethnicities, Hispanic patients with cirrhosis were associated with paradoxically lower risk of mortality with increasing community SVI. Understanding different socioeconomic mechanisms that may be associated with these outcomes may help improve care for underserved patient populations.

Introduction: Frailty, nutritional status, and comorbid conditions are all challenges that contribute to significant morbidity in patients undergoing infrainguinal arterial bypass. Evidence supports that enhanced recovery pathways (ERP) can improve perioperative outcomes. However, few studies have demonstrated successful implementation of an ERP for infrainguinal bypass (IB). The goal of this study was to demonstrate successful implementation of an ERP in a complex vascular surgery patient population undergoing IB, including elective, urgent, or emergent procedures.

Methods: Multi-stakeholder meetings were conducted to review current state, evidence-based practices and finalize an ERP for patients undergoing IB. Novel interventions included standardized patient education, minimal perioperative fasting with preoperative carbohydrate loading, opioid-sparing analgesia, and early mobilization. The ERP was initiated February 2022 and patients were enrolled at the discretion of the surgeon. At one year, patient data and process and outcome measures were abstracted from the medical record and validated by two independent reviewers for univariate analysis for all patients undergoing IB at a single institution.

Results: Over the one-year study period, 55 patients underwent IB with 29 enrolled in the ERP and 26 non-ERP. There were no significant differences in patient demographics, smoking status, or hemoglobin A1c. Almost half (46%) of patients had a tibial bypass target. ERP patients were more likely to be outpatient (58.6% vs 26.9%, p=0.04) and elective (75.9% vs 46.2%, p=0.04). ERP patient surgical indication differed from non-ERP patients (p=0.03), most notably for tissue loss (58.6% vs 30.8%) and acute limb ischemia (6.9% vs 26.9%). Compliance with ten perioperative process measures ranged from 14-100% in the ERP group. Compliance was most successful with preoperative education and chlorhexidine wash (79% and 89%, respectively), postoperative mobilization (86%), resumption of solid intake POD1 (100%), and postoperative opioid sparing strategies (100% scheduled acetaminophen). Challenges included preoperative acetaminophen and carbohydrate load (59% and 62%, respectively) and postoperative protein supplementation (14%). Outcomes for ERP patients trended toward fewer unplanned reoperations (13.8% vs 26.9%, p=0.38) and readmissions (24.1% vs 34.6%, p=0.58) when compared to non-ERP patients. Notably, ERP patients trended toward a shorter postoperative length of stay (5.9 days vs 8.4 days, p=0.22) (Table 1).

Conclusions: Our findings suggest that an ERP for IB is feasible in both elective and non-elective settings. Implementation of the ERP was associated with improved compliance with novel and preexisting process measures. Barriers to implementation include a high percentage of urgent and emergent procedures. Our results highlight the potential benefits of enhanced recovery pathways for IB and the complex vascular surgery population broadly.

Introduction: Clinical vascular surgery research has historically examined a narrow population of patients, excluding women and non-white participants. However, there is evidence that disparities in patient presentations and outcomes exist for vascular patients with diverse backgrounds. We aimed to characterize the frequency and quality of race and sex-based investigations in current vascular surgery research.

Methods: A bibliographic review of all original manuscripts published in European Journal of Vascular and Endovascular Surgery, Journal of Vascular Surgery, Journal of Vascular Surgery: Venous and Lymphatic Disorders, Journal of Endovascular Therapy, and Annals of Vascular Surgery from January 1, 2018 to December 21, 2020 was conducted. Manuscripts were evaluated for reports of race and sex in demographic information and inclusion in analysis.

Results: Evaluation of race included 2,717 manuscripts, where 622 (22.8%) reported participant race. Evaluation of sex included 2,558 articles, with 578 (22.6%) reporting participant sex. Multicenter studies were more likely to include analysis of race and sex. US-based studies were more likely to include race in evaluations, although there was no difference between US-based and non-US-based articles with regards to sex. For articles including race, 48% included race in any statistical analysis, 24% discussed racial differences in data in a Discussion section, and 5.5% reported data separately by race. In evaluations of sex-based analysis, 22.2% of articles used multivariable analysis of sex, while 4.1% analyzed sex as an independent variable. There were thirty studies (1.2%) that had equal numbers of male and female participants.

Conclusion: The rates of race and sex-based patient inclusion and data analysis in the current vascular surgery literature is low, with less than one-fourth of articles reporting either category. Investigation of the articles that did report or investigate race and sex revealed that further comparative analysis was minimal. This can make it difficult to apply study findings to the diverse population of vascular patients, despite evidence that both race and sex can affect patient outcomes.

Introduction: Perioperative venothromboembolism (VTE) chemoprophylaxis is an established tenant of bariatric surgery; however, there is little comparative data to guide medication choice. Our bariatric program switched from heparin to enoxaparin in March 2018, creating a natural experiment. The objective of this study was to determine if the change in VTE prophylaxis from heparin to enoxaparin was associated with differing rates of postoperative bleeding and VTE occurrence after bariatric surgery.

Methods: This retrospective cohort study included patients 18 years or older who underwent primary bariatric surgery (sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB)) at a single institution between March 2012 and December 2021. Subcutaneous unfractionated heparin was utilized for VTE prophylaxis from March 2012 through February 2018 and then enoxaparin was used from March 2018 through December 2021. Postoperative bleeding was defined as requiring a blood transfusion or reoperation for bleeding within 30 days of surgery. Chi-square test was used to test for differences between groups.

Results: There were 2,159 patients who underwent bariatric surgery with 1,324 (61.3%) patients in the heparin group and 835 (38.7%) in the enoxaparin group. Overall, 1,503 (69.6%) patients underwent SG and 656 (30.4%) RYGB. There was no difference in the ratio of SG to RYGB between the heparin and enoxaparin groups. Most patients were female (n=1,709, 79.2%) with a median age of 43.2 years (interquartile range (IQR): 35.6-52.2), and median BMI of 44.9 (IQR: 40.9-50.5). Overall postoperative bleeding occurred more frequently in the enoxaparin group (n=26, 3.1%) compared with the heparin group (n=12, 0.9%) (p<0.01). Additionally, reoperation for bleeding was more frequent with enoxaparin (enoxaparin 0.8% vs. heparin 0.2%, p=0.04). There was no difference in VTE occurrence between the two groups (heparin: n=14, 1.1%, enoxaparin: n=7, 0.8% (p=0.61)).

Conclusions: An institutional change from heparin to enoxaparin for bariatric surgery perioperative VTE prophylaxis was associated with a significant increase in postoperative bleeding, with no difference in VTE complications.

Introduction: Little is known about access to surgical care among people experiencing homelessness (PEH). Access-sensitive surgical conditions are preferably treated in an elective setting, though poor access to care can lead to delayed presentation, disease progression, and unplanned emergency surgery. Prevalence of surgery and rates of unplanned surgery for these conditions are considered indicators of access to care among vulnerable populations. This study aimed to (1) compare unplanned surgery rates for access-sensitive conditions between PEH and housed patients and (2) evaluate postoperative morbidity and mortality among PEH.

Methods: We performed a retrospective cohort study of patients in the Healthcare Cost and Utilization Project (HCUP) who underwent surgery in Florida, New York, or Massachusetts for access-sensitive conditions (colectomy, ventral hernia repair, abdominal aortic aneurysm repair) from 2016-2017. We identified PEH using HCUP’s “Homeless” variable and International Classification of Disease, Tenth Revision code Z59. Multivariable logistic regression evaluated associations between homelessness and serious treatable complications, morbidity, and mortality while controlling for age, gender, race, insurance, Elixhauser score, operation, hospital teaching status, and state. We also estimated the mean marginal effect of unplanned surgery on morbidity.

Results: Of 175,584 patients who underwent eligible procedures, 423 (0.2%) were PEH, compared to 1.5% of all inpatient encounters. PEH more frequently underwent unplanned surgery than housed patients (79.2% vs 43.5%, adjusted odds ratio (aOR) 3.27, p<0.001). PEH had higher odds of serious treatable complications (aOR 1.56, p=0.01), morbidity (aOR 1.35, p=0.03), and mortality (aOR 1.88, p=0.01) compared to housed patients. Morbidity rates were higher after unplanned surgery compared to elective surgery (23.3% vs 9.7%, p<0.001) for both PEH and housed patients. PEH and housed patients had similar rates of morbidity after unplanned surgery (26.0% vs 23.3%, p=0.95), but PEH undergoing elective surgery demonstrated higher odds of serious treatable complications (aOR 3.63, p<0.001) and morbidity (aOR 2.10, p=0.01). Among PEH, the mean marginal effect of unplanned surgery on odds of morbidity was 12.9% (p<0.001).

Conclusions: Our multistate cohort study demonstrated that people experiencing homelessness were underrepresented in the surgical cohort and had higher odds of unplanned surgery, underscoring significant limitations in access to care. Our results suggest that worse postoperative morbidity among PEH is partly attributable to higher rates of unplanned surgery. However, disparities after elective surgery suggests additional vulnerabilities also play a role. Policies to facilitate equitable access to safe, elective surgery for PEH may mitigate differences in rates of unplanned surgery and improve postoperative outcomes.

Introduction: Inadequate patient recruitment is the most common cause of pediatric clinical trial discontinuation. Novel data-driven approaches must be adapted to monitor, identify, and enroll all eligible patients. Recruitment of eligible patients was lagging in our ongoing stepped-wedge, cluster randomized pediatric clinical trial, ENhanced Recovery In CHildren Undergoing Surgery (ENRICH-US), to investigate the effect of enhanced recovery protocols on surgical outcomes in children after elective gastrointestinal surgery. This study sought to understand the recruitment rate of potentially eligible patients into the ENRICH-US trial, using a secondary dataset.

Methods: We performed a retrospective cross-sectional analysis using the Pediatric Health Information System (PHIS) administrative dataset to identify potentially eligible patients for the ENRICH-US trial at 10 Children’s Hospitals that are current ENRICH-US study sites, between 07/01/20 (start of ENRICH-US enrollment) and 06/24/22. Eligible patients were defined as children, ages 10 to 18, who underwent an elective gastrointestinal procedure, as defined by 76 procedural codes from International Classification of Diseases, 10th Revision. The number of potentially eligible patients identified in the PHIS data were compared to actual ENRICH-US recruited patients at each site to calculate recruitment rates.

Results: A total of 229 patients were enrolled in ENRICH-US across the 10 sites compared to 344 potentially eligible patients identified in the PHIS dataset during the study period, yielding an overall recruitment rate of 66.6%. Recruitment rates varied considerably by site, ranging from 25.0% to 97.7%. The top three enrolling sites had recruitment rates >80% (85.7%, 90.5%, 97.3%) compared to the three lowest enrolling sites which had rates<40% (25.0%, 31.6%, 36.4%). Overall, the three sites with the lowest number of potentially eligible patients identified in the PHIS dataset were also low enrollment sites. Our findings also were consistent with qualitative data from ENRICH-US that suggested high-enrollment sites had more surgeon champion engagement with many of the elective gastrointestinal surgeries being performed by a single surgeon or a small cohort of surgeons.

Conclusion: Using a secondary dataset to ascertain potentially eligible patients can be a relatively easy way to assess and monitor recruitment rates for clinical trials. Examining recruitment practices at sites with high recruitment rates may provide strategies for low recruitment rate sites.

Introduction: Neighborhood-level social determinants of health have been associated with increased firearm injury rates. However, whether factors specific to children’s lived environment are associated with incidence of pediatric firearm-related injury hospital encounters has not been assessed. This study sought to determine the relationship between ZIP Code Childhood Opportunity Index (COI) and incidence of pediatric firearm-related injury hospital encounters.

Methods: This retrospective observational cohort study combined 2015-2018 California patient-level discharge data with COI 2.0 ZIP Code data. Encounters of children less than 18 years old who presented to a hospital following firearm injury were included. The primary predictor was ZIP Code COI quintile with very low being the worst and very high the best. The primary outcome was incidence of pediatric firearm-related injury hospital encounters by ZIP Code. Secondary patient-level outcomes included patient in-hospital mortality, inpatient admission, and discharge disposition. Hot spots of pediatric firearm-related injury hospital encounters were identified through spatial analysis using Global Moran’s I and Getis-Ord Gi* statistic. Incidence of pediatric firearm-related injury hospital encounters by patient home ZIP Code COI quintile was determined and compared using incidence rate ratios. Secondary outcomes were compared by patient home ZIP Code COI quintile using Chi-squared tests.

Results: There were 2,578 pediatric firearm-related injury hospital encounters. A larger proportion of hot spots were among very low compared to very high COI ZIP Codes (n=93, 41.9% vs 2.7%, p<.001). The incidence rate ratio of pediatric firearm-related injury hospital encounters incrementally decreased with each rising quintile of COI (very low, 11.2, 95% CI 9.9-15.5 vs high, 2.9, 95% CI 2.2-3.7, p<.001). Assault was more common among very low COI ZIP Codes (57.8% vs 33.3%, p<.001). Self-inflicted injury was more common among very high COI ZIP Codes (0.5% vs 11.5%, p<.001). In-hospital mortality was highest for the very high COI quintile (n=10, 11.5%) and lowest for the very low COI quintile (n=46, 4.4%, p=0.047). There was no difference in inpatient admission nor discharge disposition by patient home ZIP Code COI quintile.

Conclusions: ZIP Codes with lower COI had higher incidence of pediatric firearm-related injury hospital encounters. Self-inflicted injury and mortality was higher among ZIP Codes with higher COI. Injury prevention efforts should tailor strategies to regional injury patterns and child-specific social determinants of health.

Introduction: Orofacial clefts are among the most common congenital malformations in the United States. Disparities in incidence, health service use and access to care among children with orofacial clefts are public health research priorities by the CDC. Understanding the national incidence of cleft lip and cleft palate is essential to expedite early surgical interventions for children with these conditions. Population-based cleft burden has remained unreported for over ten years.

Methods: We studied the most recent trends in orofacial cleft births nationally across racial and ethnic groups. Data originated from the National Birth Defect Prevention Network (NBDPN) database spanning three intervals: 2006-2010, 2010-2014, and 2014-2018. Data was sub-stratified by racial categories. Rates were calculated using the total live births reported in each maternal racial/ethnic category. Cleft prevalence was compared in each racial group to the trends in non-Hispanic Whites, cumulatively across all years.

Results: Calculated incidence rates, adjusted for national birth counts, show that Native Americans were 43.8% more likely to have cleft lip +/- palate (CI [1.328, 1.558], p<0.0001) and 36.0% more likely to have cleft palate alone (CI [1.233 to 1.499], p<0.0001) compared to White, non-Hispanics. Incidence of cleft lip +/- palate in non-Hispanic Blacks (OR=0.6381, CI [0.6159, 0.6611]) and Asians (OR=0.6278, CI [0.5961 to 0.6612]) were significantly lower than in non-Hispanic Whites (p<0.0001). Rates of cleft palate alone were significantly lower in Black, non-Hispanics (OR=0.641, CI [0.6146, 0.6686], p<0.0001), Asians (OR=0.6871, CI [0.6476, 0.7290], p<0.0001), and Hispanics/Latinos (OR=0.8101, CI [0.7848, 0.8363], p<0.0001).

Conclusions: We show significantly increased orofacial cleft prevalence in Native Americans, and significant differences in cleft birth prevalence in all other studied minority racial and ethnic groups as compared to White, non-Hispanic children. Our results will guide plastic surgeons to think critically about disparities in incidence and risk factors for orofacial clefts, especially in vulnerable populations.

Introduction: An esophagectomy, which is the removal of part or all of the esophagus, is considered a complex surgical procedure[1]. While historically done via open surgery, there has been a shift in the last decade to a minimally invasive esophagectomy (MIE) to reduce the significant morbidity associated with the procedure[2 3]. The objective of this study was to compare survival and complication rates for open versus minimally invasive esophagectomy.

Methods: A retrospective cohort analysis of the American College of Surgeons National Surgical Quality Improvement Program (ASC NSQIP) Esophagectomy Procedure Target Data File was conducted [4]. All patients aged 18-90 who underwent esophagectomy at NSQIP reporting hospitals between 2016 to 2020 were included in this study. The primary outcome was death at 30 days. Secondary outcomes included anastomotic leak, bleeding complications, surgical site infections, unplanned readmissions, and reoperations. A multivariable logistic regression was performed for primary outcome with results significant at the 0.05 level reported.

Results: A total of 12,769 esophagectomies were performed at NSQIP participating hospitals between 2016-2020. After exclusion of 3629 patients for missing surgical approach data or missing outcome data, a total of 9,140 patients were included for analysis. The total number of MIE was 5644, the total number of open esophagectomies (OE) was 3496. The rate of MIE increased overall between 2016-2020, whereas the rate of OE was stable. In an adjusted multivariable logistic regression, patients who underwent OE had a 100% increase in odds of death at 30 days (OR 2.08 [1.18,3.64]). Patients who underwent OE had a 128% increased odds of bleeding complications. In an adjusted multivariable linear regression, operative time was increased on average by 88 minutes for MIE compared to OE. There was no statistically significant difference in risk of anastomotic leak requiring intervention between the two groups. Compared to non-Hispanic white patients, non-Hispanic Black patients were at 150% increased odds of bleeding complications, but 15% decreased odds of death at 30 days. Women had higher odds of both death at 30 days and bleeding complications compared to men in this cohort.

Conclusions: Our study further highlights the decreased morbidity and mortality associated with MIE compared to OE. However, esophagectomies overall remain an intricate procedure which requires significant expertise regardless of operative approach. Ensuring hospitals have appropriate resources to support performance of these complex procedures will improve patient care and outcomes.

Introduction: Venous thromboembolism (VTE) represents a major source of preventable morbidity and mortality and is a leading cause of death in the U.S. after cancer surgery. Though guidelines for both inpatient and post-discharge chemoprophylaxis have existed for abdominopelvic malignancies treated by General Surgery, no guidelines for post-discharge chemoprophylaxis existed for Thoracic Surgery until 2021. The purpose of this study is to determine VTE rates for General (GS) and Thoracic Surgery (TS), as well as the association between guidelines and rates of post-discharge VTE chemoprophylaxis use within the VHA.

Methods: The VA Corporate Data Warehouse, Pharmacy Benefits Management database and the Veterans Affairs Surgical Quality Improvement Program database (VASQIP) was used to identify patients who underwent surgery for cancer with GS or TS between 2015-2018. During the study period, guidelines for post-discharge VTE chemoprophylaxis existed only for GS. Rates of postoperative VTE events within 30 days of surgery and VTE chemoprophylaxis adherence were determined. Multivariable Poisson regression was used to determine incidence-rate ratios (IRR) of post-discharge chemoprophylaxis adherence by surgical specialty.

Results: Overall, 6,314 patients treated at 90 hospitals nationwide were included. All patients were high-risk for VTE, with an overall postoperative VTE rate of 1.9% (n=121). Specialty-specific VTE rates were similar for GS (1.9%) and TS (2.1%). Overall, 10.1% of patients received post-discharge chemoprophylaxis. GS (12.8%) prescribed post-discharge chemoprophylaxis more commonly in accordance with guidelines than TS (1.1%) did in absence of specialty-specific guidelines (p<0.001). Also, VTE rates were higher among patients who received esophageal surgery with TS (3.5%) than esophagogastric surgery with GS (2.4%) (p<0.001). Further, only 0.9% of patients who underwent esophageal surgery with TS received post-discharge chemoprophylaxis compared with 14.9% of esophagogastric surgery patients treated by GS (p<0.001). In adjusted multivariable analysis, TS was much less likely to prescribe post-discharge chemoprophylaxis to patients (IRR 0.08, 95% CI 0.02-0.26 versus GS).

Conclusion: The postoperative VTE rate within the VHA is variable by procedure site. Compared to General Surgery, prescribing of post-discharge chemoprophylaxis by Thoracic Surgery was rare in absence of specialty-specific guidelines. Implementation of new post-discharge chemoprophylaxis guidelines for Thoracic Surgery may reduce VTE rates among high-risk patients.

Introduction: Culture drives organizational outcomes, and leaders play a critical role in shaping culture. How chairs influence departmental culture change is poorly understood.

Methods: We visited 15 general surgery residency programs, based on their reputations for surgeon well-being and their residents’ responses to a national survey about the learning environment. Semi-structured interviews with department chairs were conducted. A codebook was developed, blending a theoretical model and emergent codes.

Results: 14 chairs were interviewed, having served in their positions for 4 months - 14 years. 29% were women, and 0.07% belonged to minoritized racial/ethnic groups. Chairs described their Vision, strategies for execution (the Method), and challenges (the Madness). Visions ranged from nonexistent to multifaceted, with corresponding variations in their preparation and goal setting. Critical execution strategies included taking time to understand the existing organization and people, engaging allies, practicing transparency, allowing for discomfort en route to growth, and leading by example (e.g., with vulnerability or humility). Challenges identified were particularly relevant to diversity, equity, and inclusion efforts and arose from managing disruptive faculty and fears of being accused of favoritism.

Conclusion: Despite articulating different visions, chairs of culturally notable departments were aligned in their learned strategies for executing them. Challenges derived from other faculty’s resistance to change and internalized pressures, and chairs found perspective sharing to be a powerful tool in addressing these challenges. Ultimately, progress is dependent on chairs overcoming others’ and their own discomfort with their decisions.