ASC 2016

JACKSONVILLE, FLA. – Patients who have HIV are at no greater risk of complications from appendectomy than are non-HIV patients according to an analysis of cases in a national surgical database presented at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.

Dr. Michael C. Smith of the State University of New York, Brooklyn, explained why he and his colleagues felt it was time to update the literature on HIV and surgery. “Much of the literature on appendectomy in the setting of HIV is either from the early 1990s or elsewhere in the world, and it shows greatly increased complication rates in these patients,” he said.

The analysis queried the Nationwide Inpatient Sample (NIS) database for all patients who had acute appendicitis and appendectomy during 2005-2012. The analysis included patients who had both open and laparoscopic appendectomy, and compared the HIV group that did not have AIDS with the non-HIV group, Dr. Smith said. The population with AIDS, along with patients who had interval appendectomies after appendicitis, were excluded.

The study looked at 821 patients with HIV and 338,425 patients without HIV as controls.

“The only significant difference we found between the two groups was hospital length of stay, which differed by about three-quarters of a day,” Dr. Smith said. Patients with HIV spent on average 3.8 days in the hospital after appendectomy vs. 3 days for non-HIV patients. “Other complication rates were nonsignificant by our study,” he said.

The average total charge for HIV patients was also higher, $33,350 vs. $30,714, the analysis showed.

Dr. Smith acknowledged some limitations in using the NIS database, most notably that the data were from index hospitalizations only. “So we probably did not capture people who returned to the hospital on postoperative day 3, 4, and 5 after they were discharged home,” he said. “Therefore, prospective studies are needed to validate these results.”

He also said that the study did not differentiate between operations for perforated and nonperforated appendix, and he and his coresearchers could not determine why the HIV population had longer hospital stays.

Dr. Smith and coauthors had no financial relationships to disclose.

JACKSONVILLE, FLA. – Patients who have HIV are at no greater risk of complications from appendectomy than are non-HIV patients according to an analysis of cases in a national surgical database presented at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.

Dr. Michael C. Smith of the State University of New York, Brooklyn, explained why he and his colleagues felt it was time to update the literature on HIV and surgery. “Much of the literature on appendectomy in the setting of HIV is either from the early 1990s or elsewhere in the world, and it shows greatly increased complication rates in these patients,” he said.

The analysis queried the Nationwide Inpatient Sample (NIS) database for all patients who had acute appendicitis and appendectomy during 2005-2012. The analysis included patients who had both open and laparoscopic appendectomy, and compared the HIV group that did not have AIDS with the non-HIV group, Dr. Smith said. The population with AIDS, along with patients who had interval appendectomies after appendicitis, were excluded.

The study looked at 821 patients with HIV and 338,425 patients without HIV as controls.

“The only significant difference we found between the two groups was hospital length of stay, which differed by about three-quarters of a day,” Dr. Smith said. Patients with HIV spent on average 3.8 days in the hospital after appendectomy vs. 3 days for non-HIV patients. “Other complication rates were nonsignificant by our study,” he said.

The average total charge for HIV patients was also higher, $33,350 vs. $30,714, the analysis showed.

Dr. Smith acknowledged some limitations in using the NIS database, most notably that the data were from index hospitalizations only. “So we probably did not capture people who returned to the hospital on postoperative day 3, 4, and 5 after they were discharged home,” he said. “Therefore, prospective studies are needed to validate these results.”

He also said that the study did not differentiate between operations for perforated and nonperforated appendix, and he and his coresearchers could not determine why the HIV population had longer hospital stays.

Dr. Smith and coauthors had no financial relationships to disclose.

JACKSONVILLE, FLA. – Patients who have HIV are at no greater risk of complications from appendectomy than are non-HIV patients according to an analysis of cases in a national surgical database presented at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.

Dr. Michael C. Smith of the State University of New York, Brooklyn, explained why he and his colleagues felt it was time to update the literature on HIV and surgery. “Much of the literature on appendectomy in the setting of HIV is either from the early 1990s or elsewhere in the world, and it shows greatly increased complication rates in these patients,” he said.

The analysis queried the Nationwide Inpatient Sample (NIS) database for all patients who had acute appendicitis and appendectomy during 2005-2012. The analysis included patients who had both open and laparoscopic appendectomy, and compared the HIV group that did not have AIDS with the non-HIV group, Dr. Smith said. The population with AIDS, along with patients who had interval appendectomies after appendicitis, were excluded.

The study looked at 821 patients with HIV and 338,425 patients without HIV as controls.

“The only significant difference we found between the two groups was hospital length of stay, which differed by about three-quarters of a day,” Dr. Smith said. Patients with HIV spent on average 3.8 days in the hospital after appendectomy vs. 3 days for non-HIV patients. “Other complication rates were nonsignificant by our study,” he said.

The average total charge for HIV patients was also higher, $33,350 vs. $30,714, the analysis showed.

Dr. Smith acknowledged some limitations in using the NIS database, most notably that the data were from index hospitalizations only. “So we probably did not capture people who returned to the hospital on postoperative day 3, 4, and 5 after they were discharged home,” he said. “Therefore, prospective studies are needed to validate these results.”

He also said that the study did not differentiate between operations for perforated and nonperforated appendix, and he and his coresearchers could not determine why the HIV population had longer hospital stays.

Dr. Smith and coauthors had no financial relationships to disclose.

JACKSONVILLE, FLA. The potential of “big data” to predict surgical complications has long been expected and that potential may now in the process of becoming a reality.

As health care moves to a value-based system that penalizes surgeons and hospitals for readmissions, the inability to predict postop complications remains a problem, but investigators at University of Wisconsin have found a way to use “big data” to create a model that may help surgeons identify at-risk individuals before complications occur.

Shara Feld, Ph.D., a medical student at Wisconsin, reported on the development of a Markov chain model that sequences random variables to calculate varying states over time. “A Markov model represents the patient progression through a series of health states,” Dr. Feld said at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress

“A Markov chain model combining information about prior complications and the time to occurrence after surgery can inform our likelihood of specific future complications,” she said. “Understanding these relationships among complications can improve our ability to select targeted interventions, to avoid cascades of multiple complications, counsel patients and family on prognosis, assist with care decisions, and develop quality improvement measures.”

The model draws on 3 million operations in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database from 2005 to 2013. Of those, 400,000 cases involved one complication and 132,000 two or more complications, Dr. Feld said. From that, the investigators identified 21 different complications, including superficial, deep and organ surgical site infections, cardiac arrest, and pneumonia. The study accounted for complications within 30 days of the operation.

Dr. Feld pointed to one of the challenges using the existing literature on surgical risk assessment: “We know that patients can have one complication that can snowball into multiple complications, and as this snowball of complications develops, the postoperative risk in patient prognosis can change from what it was based on preoperative risk factors,” she said.

The model was best at predicting death, coma longer than a day, cardiac arrest, septic shock, renal failure, pneumonia, unplanned reintubation, ventilator use of more than 2 days, and bleeding transfusion, Dr. Feld said.

The study also found that complications most likely to cascade to a higher level were cardiac arrest, renal insufficiency or failure, stroke, intubation, septic shock, and coma, Dr. Feld said. For example, a patient who has a coma has an odds ratio greater than 1.5 of dying within 30 days of the operation while the odds ratio for death following a diagnosis of superficial surgical site infection is less than 0.5, the study found.

Evaluating population-based complication risks after surgery was difficult before the large ACS NSQIP database became available to researchers, Dr. Feld said. The model reveals the impact of specific complications, complication timing, and how combinations of multiple postoperative complications change the risk for the development of future complications..

This model has not to date looked at what type of procedure led to the complications but this line of research may be developed in the future, Dr. Feld said.

The authors had no financial relationships to disclose.

JACKSONVILLE, FLA. The potential of “big data” to predict surgical complications has long been expected and that potential may now in the process of becoming a reality.

As health care moves to a value-based system that penalizes surgeons and hospitals for readmissions, the inability to predict postop complications remains a problem, but investigators at University of Wisconsin have found a way to use “big data” to create a model that may help surgeons identify at-risk individuals before complications occur.

Shara Feld, Ph.D., a medical student at Wisconsin, reported on the development of a Markov chain model that sequences random variables to calculate varying states over time. “A Markov model represents the patient progression through a series of health states,” Dr. Feld said at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress

“A Markov chain model combining information about prior complications and the time to occurrence after surgery can inform our likelihood of specific future complications,” she said. “Understanding these relationships among complications can improve our ability to select targeted interventions, to avoid cascades of multiple complications, counsel patients and family on prognosis, assist with care decisions, and develop quality improvement measures.”

The model draws on 3 million operations in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database from 2005 to 2013. Of those, 400,000 cases involved one complication and 132,000 two or more complications, Dr. Feld said. From that, the investigators identified 21 different complications, including superficial, deep and organ surgical site infections, cardiac arrest, and pneumonia. The study accounted for complications within 30 days of the operation.

Dr. Feld pointed to one of the challenges using the existing literature on surgical risk assessment: “We know that patients can have one complication that can snowball into multiple complications, and as this snowball of complications develops, the postoperative risk in patient prognosis can change from what it was based on preoperative risk factors,” she said.

The model was best at predicting death, coma longer than a day, cardiac arrest, septic shock, renal failure, pneumonia, unplanned reintubation, ventilator use of more than 2 days, and bleeding transfusion, Dr. Feld said.

The study also found that complications most likely to cascade to a higher level were cardiac arrest, renal insufficiency or failure, stroke, intubation, septic shock, and coma, Dr. Feld said. For example, a patient who has a coma has an odds ratio greater than 1.5 of dying within 30 days of the operation while the odds ratio for death following a diagnosis of superficial surgical site infection is less than 0.5, the study found.

Evaluating population-based complication risks after surgery was difficult before the large ACS NSQIP database became available to researchers, Dr. Feld said. The model reveals the impact of specific complications, complication timing, and how combinations of multiple postoperative complications change the risk for the development of future complications..

This model has not to date looked at what type of procedure led to the complications but this line of research may be developed in the future, Dr. Feld said.

The authors had no financial relationships to disclose.

JACKSONVILLE, FLA. The potential of “big data” to predict surgical complications has long been expected and that potential may now in the process of becoming a reality.

As health care moves to a value-based system that penalizes surgeons and hospitals for readmissions, the inability to predict postop complications remains a problem, but investigators at University of Wisconsin have found a way to use “big data” to create a model that may help surgeons identify at-risk individuals before complications occur.

Shara Feld, Ph.D., a medical student at Wisconsin, reported on the development of a Markov chain model that sequences random variables to calculate varying states over time. “A Markov model represents the patient progression through a series of health states,” Dr. Feld said at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress

“A Markov chain model combining information about prior complications and the time to occurrence after surgery can inform our likelihood of specific future complications,” she said. “Understanding these relationships among complications can improve our ability to select targeted interventions, to avoid cascades of multiple complications, counsel patients and family on prognosis, assist with care decisions, and develop quality improvement measures.”

The model draws on 3 million operations in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database from 2005 to 2013. Of those, 400,000 cases involved one complication and 132,000 two or more complications, Dr. Feld said. From that, the investigators identified 21 different complications, including superficial, deep and organ surgical site infections, cardiac arrest, and pneumonia. The study accounted for complications within 30 days of the operation.

Dr. Feld pointed to one of the challenges using the existing literature on surgical risk assessment: “We know that patients can have one complication that can snowball into multiple complications, and as this snowball of complications develops, the postoperative risk in patient prognosis can change from what it was based on preoperative risk factors,” she said.

The model was best at predicting death, coma longer than a day, cardiac arrest, septic shock, renal failure, pneumonia, unplanned reintubation, ventilator use of more than 2 days, and bleeding transfusion, Dr. Feld said.

The study also found that complications most likely to cascade to a higher level were cardiac arrest, renal insufficiency or failure, stroke, intubation, septic shock, and coma, Dr. Feld said. For example, a patient who has a coma has an odds ratio greater than 1.5 of dying within 30 days of the operation while the odds ratio for death following a diagnosis of superficial surgical site infection is less than 0.5, the study found.

Evaluating population-based complication risks after surgery was difficult before the large ACS NSQIP database became available to researchers, Dr. Feld said. The model reveals the impact of specific complications, complication timing, and how combinations of multiple postoperative complications change the risk for the development of future complications..

This model has not to date looked at what type of procedure led to the complications but this line of research may be developed in the future, Dr. Feld said.

The authors had no financial relationships to disclose.

JACKSONVILLE, FLA. – About one-third of patients admitted to the hospital for abdominal problems like diverticulitis and small bowel obstruction get discharged without having surgery, but their outcomes are not typically included in quality assessment, leaving this group of patients in a “blind spot” of surgical quality, according to Dr. Michael Wandling.

However, researchers from Northwestern University in Chicago have analyzed data from the Nationwide (National) Inpatient Sample and determined how many cases of diverticulitis, small bowel obstruction (SBO), cholecystitis, and acute appendicitis are managed without surgery and the clinical factors that may influence that, he reported at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.

Richard Mark Kirkner

“Surgeons frequently will admit patients for nonoperative management of diagnoses such as diverticulitis, small bowel obstruction, cholecystitis, and perforated appendicitis,” said Dr. Wandling, a general surgery resident at Northwestern. “Yet nonoperative management does not really factor into current surgical quality assessment. In fact, nonoperative management is not frequently evaluated, and utilization rates have not even really been quantified.”

The researchers’ goal was to evaluate hospital-level variability in nonoperative management practices and identify hospital characteristics associated with high rates of nonoperative management, Dr. Wandling said.

“What we found was that smaller bed size, fewer annual discharges, being a public government-run hospital, being a nonteaching hospital, and being rural or located in the Midwest were all associated with greater use of nonoperative management,” he said.

They extracted a sample from the Nationwide (National) Inpatient Sample that analyzed admission and discharge data on 1.6 million patients admitted for one of the four studied diagnoses from 1998 to 2011. Overall, the four diagnoses accounted for more than 500,000 annual admissions, “and this rate has been increasing over time,” Dr. Wandling said. To calculate rates of nonoperative management for each diagnosis, the researchers concentrated on data from 2010 and 2011. They found the following rates of nonoperative management: 87.1% for diverticulitis, 38.1% for SBO, 11.3% for cholecystitis, and 3.7% for appendicitis. The overall rate of nonoperative management for all four diagnoses was 32.8%, Dr. Wandling said.

They also evaluated the overall rates of nonoperative management for each year from 1998 to 2011 and found they steadily increased from 25.6% to 32.8%, Dr. Wandling said. “Nonoperative management is not uncommon, with approximately 190,000 patients being admitted for nonoperative management each year, and this number has also been increasing,” he said.

Dr. Wandling acknowledged some limitations with the study because it used an administrative dataset with data collected retrospectively and because the data do not track patients after discharge, making it impossible to know if any patients managed nonoperatively were subsequently readmitted for surgery. “Current surgical quality assessment only focuses on patients who have surgery, which can be seen through public reporting programs like Hospital Compare, pay-for-performance initiatives like [Centers for Medicare & Medicaid Services] valued-based purchasing, and clinical data registries,” he said. “As a result, patients who are managed nonoperatively are really left in a blind spot of surgical quality.”

Dr. Wandling said he and his coauthors are working with the American College of Surgeons National Surgical Quality Improvement Program to develop an Emergency General Surgery (EGS) Pilot to evaluate performance in operative and nonoperative care for SBO, cholecystitis, and appendicitis. Fourteen centers have so far collected more than 6 months of data as part of the EGS Pilot, he said, and additional hospitals are currently being recruited to participate.

“Ultimately the goal is to identify optimal nonoperative management strategies in general surgery so that all patients can receive high-quality surgical care, not just those who we operate on,” Dr. Wandling said.

He and his coauthors had no relevant financial disclosures.

JACKSONVILLE, FLA. – About one-third of patients admitted to the hospital for abdominal problems like diverticulitis and small bowel obstruction get discharged without having surgery, but their outcomes are not typically included in quality assessment, leaving this group of patients in a “blind spot” of surgical quality, according to Dr. Michael Wandling.

However, researchers from Northwestern University in Chicago have analyzed data from the Nationwide (National) Inpatient Sample and determined how many cases of diverticulitis, small bowel obstruction (SBO), cholecystitis, and acute appendicitis are managed without surgery and the clinical factors that may influence that, he reported at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.

Richard Mark Kirkner

“Surgeons frequently will admit patients for nonoperative management of diagnoses such as diverticulitis, small bowel obstruction, cholecystitis, and perforated appendicitis,” said Dr. Wandling, a general surgery resident at Northwestern. “Yet nonoperative management does not really factor into current surgical quality assessment. In fact, nonoperative management is not frequently evaluated, and utilization rates have not even really been quantified.”

The researchers’ goal was to evaluate hospital-level variability in nonoperative management practices and identify hospital characteristics associated with high rates of nonoperative management, Dr. Wandling said.

“What we found was that smaller bed size, fewer annual discharges, being a public government-run hospital, being a nonteaching hospital, and being rural or located in the Midwest were all associated with greater use of nonoperative management,” he said.

They extracted a sample from the Nationwide (National) Inpatient Sample that analyzed admission and discharge data on 1.6 million patients admitted for one of the four studied diagnoses from 1998 to 2011. Overall, the four diagnoses accounted for more than 500,000 annual admissions, “and this rate has been increasing over time,” Dr. Wandling said. To calculate rates of nonoperative management for each diagnosis, the researchers concentrated on data from 2010 and 2011. They found the following rates of nonoperative management: 87.1% for diverticulitis, 38.1% for SBO, 11.3% for cholecystitis, and 3.7% for appendicitis. The overall rate of nonoperative management for all four diagnoses was 32.8%, Dr. Wandling said.

They also evaluated the overall rates of nonoperative management for each year from 1998 to 2011 and found they steadily increased from 25.6% to 32.8%, Dr. Wandling said. “Nonoperative management is not uncommon, with approximately 190,000 patients being admitted for nonoperative management each year, and this number has also been increasing,” he said.

Dr. Wandling acknowledged some limitations with the study because it used an administrative dataset with data collected retrospectively and because the data do not track patients after discharge, making it impossible to know if any patients managed nonoperatively were subsequently readmitted for surgery. “Current surgical quality assessment only focuses on patients who have surgery, which can be seen through public reporting programs like Hospital Compare, pay-for-performance initiatives like [Centers for Medicare & Medicaid Services] valued-based purchasing, and clinical data registries,” he said. “As a result, patients who are managed nonoperatively are really left in a blind spot of surgical quality.”

Dr. Wandling said he and his coauthors are working with the American College of Surgeons National Surgical Quality Improvement Program to develop an Emergency General Surgery (EGS) Pilot to evaluate performance in operative and nonoperative care for SBO, cholecystitis, and appendicitis. Fourteen centers have so far collected more than 6 months of data as part of the EGS Pilot, he said, and additional hospitals are currently being recruited to participate.

“Ultimately the goal is to identify optimal nonoperative management strategies in general surgery so that all patients can receive high-quality surgical care, not just those who we operate on,” Dr. Wandling said.

He and his coauthors had no relevant financial disclosures.

JACKSONVILLE, FLA. – About one-third of patients admitted to the hospital for abdominal problems like diverticulitis and small bowel obstruction get discharged without having surgery, but their outcomes are not typically included in quality assessment, leaving this group of patients in a “blind spot” of surgical quality, according to Dr. Michael Wandling.

However, researchers from Northwestern University in Chicago have analyzed data from the Nationwide (National) Inpatient Sample and determined how many cases of diverticulitis, small bowel obstruction (SBO), cholecystitis, and acute appendicitis are managed without surgery and the clinical factors that may influence that, he reported at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.

Richard Mark Kirkner

“Surgeons frequently will admit patients for nonoperative management of diagnoses such as diverticulitis, small bowel obstruction, cholecystitis, and perforated appendicitis,” said Dr. Wandling, a general surgery resident at Northwestern. “Yet nonoperative management does not really factor into current surgical quality assessment. In fact, nonoperative management is not frequently evaluated, and utilization rates have not even really been quantified.”

The researchers’ goal was to evaluate hospital-level variability in nonoperative management practices and identify hospital characteristics associated with high rates of nonoperative management, Dr. Wandling said.

“What we found was that smaller bed size, fewer annual discharges, being a public government-run hospital, being a nonteaching hospital, and being rural or located in the Midwest were all associated with greater use of nonoperative management,” he said.

They extracted a sample from the Nationwide (National) Inpatient Sample that analyzed admission and discharge data on 1.6 million patients admitted for one of the four studied diagnoses from 1998 to 2011. Overall, the four diagnoses accounted for more than 500,000 annual admissions, “and this rate has been increasing over time,” Dr. Wandling said. To calculate rates of nonoperative management for each diagnosis, the researchers concentrated on data from 2010 and 2011. They found the following rates of nonoperative management: 87.1% for diverticulitis, 38.1% for SBO, 11.3% for cholecystitis, and 3.7% for appendicitis. The overall rate of nonoperative management for all four diagnoses was 32.8%, Dr. Wandling said.

They also evaluated the overall rates of nonoperative management for each year from 1998 to 2011 and found they steadily increased from 25.6% to 32.8%, Dr. Wandling said. “Nonoperative management is not uncommon, with approximately 190,000 patients being admitted for nonoperative management each year, and this number has also been increasing,” he said.

Dr. Wandling acknowledged some limitations with the study because it used an administrative dataset with data collected retrospectively and because the data do not track patients after discharge, making it impossible to know if any patients managed nonoperatively were subsequently readmitted for surgery. “Current surgical quality assessment only focuses on patients who have surgery, which can be seen through public reporting programs like Hospital Compare, pay-for-performance initiatives like [Centers for Medicare & Medicaid Services] valued-based purchasing, and clinical data registries,” he said. “As a result, patients who are managed nonoperatively are really left in a blind spot of surgical quality.”

Dr. Wandling said he and his coauthors are working with the American College of Surgeons National Surgical Quality Improvement Program to develop an Emergency General Surgery (EGS) Pilot to evaluate performance in operative and nonoperative care for SBO, cholecystitis, and appendicitis. Fourteen centers have so far collected more than 6 months of data as part of the EGS Pilot, he said, and additional hospitals are currently being recruited to participate.

“Ultimately the goal is to identify optimal nonoperative management strategies in general surgery so that all patients can receive high-quality surgical care, not just those who we operate on,” Dr. Wandling said.

He and his coauthors had no relevant financial disclosures.

JACKSONVILLE, FLA. – Voice quality changes after thyroid surgery are detectable by using both subjective and objective measures, according to investigators at Monash University in Melbourne, Australia.

After thyroid surgery, up to 80% of patients with functional recurrent laryngeal nerves (RLNs) have reported voice changes, so the investigators set out to evaluate the extent of those voice changes and how the extent of the operation and RLN edema may affect them.

“It has been confirmed that thyroid procedures do alter the voice without necessarily causing a measurable recurrent laryngeal nerve palsy,” said lead investigator Dr. James Lee, “and the change of voice is correlated to the extent of surgery and the amount of nerve swelling.” The findings were presented at the Association of Academic Surgery/Society of University Surgeons Academic Surgical Congress.

The study evaluated 62 patients who had total and partial thyroidectomy surgery between 2010 and 2011 at the Monash University Endocrine Surgery Unit. To subjectively measure voice quality after surgery, the researchers used the Voice Disorder Index (VDI), which measures voice quality on a 0-40 scale from best to worst. After surgery, the mean VDI score in this group showed a 5.2 plus or minus 1.2–point deterioration from 4.2 to 9.4 (P less than .001). For objective evaluation, the researchers used the Dysphonia Severity Index (DSI), which scores voice quality on a scale of –5 to 5 from worst to best. After surgery, the mean DSI score showed a 1.1 plus or minus 0.2–point deterioration from 3.9 to 2.8 (P less than .001). Two speech pathologists conducted the voice assessments.

“Subjective scoring of both hemithyroidectomy and total thyroidectomy reported worse voice postoperatively,” Dr. Lee said. “However, when you take a close look at the numbers, those undergoing total thyroidectomy reported a higher measure of deterioration in their voice.”

Patients who had either partial and total thyroidectomy reported significant subjective deterioration of their voice with mean VDI change from 5.4 to 7.9 (P = 0.02) and 3.5 to 10.6 (P less than .001), respectively. However, on objective evaluation, only the total thyroidectomy patients showed significant voice deterioration, with a mean DSI change from 4 to 2.5 (P less than .001).

Dr. Lee noted that study outcomes between partial and total thyroidectomy patients diverged in another respect: the impact RLN swelling had on voice deterioration. To evaluate RLN swelling, the researchers measured the diameter of the nerve with Vernier calipers before and after the lobectomy during each operation. RLN diameter increased 0.58 plus or minus 0.05 mm on average (P less than .001). In patients who had partial thyroidectomy, the greater the RLN swelling, the worse the subjective score (P = .03). This was not the case in the total thyroidectomy patients where involvement of two nerves complicates the interaction, he said.

During follow-up, the investigators came upon a revelatory finding. “With median 8-month follow-up, the self-reported, VDI scores had returned to baseline levels,” Dr. Lee said. “Interestingly, not only did the objective DSI scores show a return to baseline levels, but it exceeded the baseline levels, meaning the voice had scored better after surgery than before.” However, he noted only 13 patients completed the follow-up.

“Voice change post-thyroidectomy without recurrent laryngeal nerve injury is a complex phenomenon and is likely multifactorial, and we only looked at two of those factors: the extent of surgery and the gradient of recurrent laryngeal nerve injury with nerve edema as a surrogate,” Dr. Lee said. Future studies should evaluate other factors, including the role of the external branch of the superior laryngeal nerve and patient factors such as diabetes or smoking, he said.

Dr. Lee and his coauthors had no disclosures.

JACKSONVILLE, FLA. – Voice quality changes after thyroid surgery are detectable by using both subjective and objective measures, according to investigators at Monash University in Melbourne, Australia.

After thyroid surgery, up to 80% of patients with functional recurrent laryngeal nerves (RLNs) have reported voice changes, so the investigators set out to evaluate the extent of those voice changes and how the extent of the operation and RLN edema may affect them.

“It has been confirmed that thyroid procedures do alter the voice without necessarily causing a measurable recurrent laryngeal nerve palsy,” said lead investigator Dr. James Lee, “and the change of voice is correlated to the extent of surgery and the amount of nerve swelling.” The findings were presented at the Association of Academic Surgery/Society of University Surgeons Academic Surgical Congress.

The study evaluated 62 patients who had total and partial thyroidectomy surgery between 2010 and 2011 at the Monash University Endocrine Surgery Unit. To subjectively measure voice quality after surgery, the researchers used the Voice Disorder Index (VDI), which measures voice quality on a 0-40 scale from best to worst. After surgery, the mean VDI score in this group showed a 5.2 plus or minus 1.2–point deterioration from 4.2 to 9.4 (P less than .001). For objective evaluation, the researchers used the Dysphonia Severity Index (DSI), which scores voice quality on a scale of –5 to 5 from worst to best. After surgery, the mean DSI score showed a 1.1 plus or minus 0.2–point deterioration from 3.9 to 2.8 (P less than .001). Two speech pathologists conducted the voice assessments.

“Subjective scoring of both hemithyroidectomy and total thyroidectomy reported worse voice postoperatively,” Dr. Lee said. “However, when you take a close look at the numbers, those undergoing total thyroidectomy reported a higher measure of deterioration in their voice.”

Patients who had either partial and total thyroidectomy reported significant subjective deterioration of their voice with mean VDI change from 5.4 to 7.9 (P = 0.02) and 3.5 to 10.6 (P less than .001), respectively. However, on objective evaluation, only the total thyroidectomy patients showed significant voice deterioration, with a mean DSI change from 4 to 2.5 (P less than .001).

Dr. Lee noted that study outcomes between partial and total thyroidectomy patients diverged in another respect: the impact RLN swelling had on voice deterioration. To evaluate RLN swelling, the researchers measured the diameter of the nerve with Vernier calipers before and after the lobectomy during each operation. RLN diameter increased 0.58 plus or minus 0.05 mm on average (P less than .001). In patients who had partial thyroidectomy, the greater the RLN swelling, the worse the subjective score (P = .03). This was not the case in the total thyroidectomy patients where involvement of two nerves complicates the interaction, he said.

During follow-up, the investigators came upon a revelatory finding. “With median 8-month follow-up, the self-reported, VDI scores had returned to baseline levels,” Dr. Lee said. “Interestingly, not only did the objective DSI scores show a return to baseline levels, but it exceeded the baseline levels, meaning the voice had scored better after surgery than before.” However, he noted only 13 patients completed the follow-up.

“Voice change post-thyroidectomy without recurrent laryngeal nerve injury is a complex phenomenon and is likely multifactorial, and we only looked at two of those factors: the extent of surgery and the gradient of recurrent laryngeal nerve injury with nerve edema as a surrogate,” Dr. Lee said. Future studies should evaluate other factors, including the role of the external branch of the superior laryngeal nerve and patient factors such as diabetes or smoking, he said.

Dr. Lee and his coauthors had no disclosures.

JACKSONVILLE, FLA. – Voice quality changes after thyroid surgery are detectable by using both subjective and objective measures, according to investigators at Monash University in Melbourne, Australia.

After thyroid surgery, up to 80% of patients with functional recurrent laryngeal nerves (RLNs) have reported voice changes, so the investigators set out to evaluate the extent of those voice changes and how the extent of the operation and RLN edema may affect them.

“It has been confirmed that thyroid procedures do alter the voice without necessarily causing a measurable recurrent laryngeal nerve palsy,” said lead investigator Dr. James Lee, “and the change of voice is correlated to the extent of surgery and the amount of nerve swelling.” The findings were presented at the Association of Academic Surgery/Society of University Surgeons Academic Surgical Congress.

The study evaluated 62 patients who had total and partial thyroidectomy surgery between 2010 and 2011 at the Monash University Endocrine Surgery Unit. To subjectively measure voice quality after surgery, the researchers used the Voice Disorder Index (VDI), which measures voice quality on a 0-40 scale from best to worst. After surgery, the mean VDI score in this group showed a 5.2 plus or minus 1.2–point deterioration from 4.2 to 9.4 (P less than .001). For objective evaluation, the researchers used the Dysphonia Severity Index (DSI), which scores voice quality on a scale of –5 to 5 from worst to best. After surgery, the mean DSI score showed a 1.1 plus or minus 0.2–point deterioration from 3.9 to 2.8 (P less than .001). Two speech pathologists conducted the voice assessments.

“Subjective scoring of both hemithyroidectomy and total thyroidectomy reported worse voice postoperatively,” Dr. Lee said. “However, when you take a close look at the numbers, those undergoing total thyroidectomy reported a higher measure of deterioration in their voice.”

Patients who had either partial and total thyroidectomy reported significant subjective deterioration of their voice with mean VDI change from 5.4 to 7.9 (P = 0.02) and 3.5 to 10.6 (P less than .001), respectively. However, on objective evaluation, only the total thyroidectomy patients showed significant voice deterioration, with a mean DSI change from 4 to 2.5 (P less than .001).

Dr. Lee noted that study outcomes between partial and total thyroidectomy patients diverged in another respect: the impact RLN swelling had on voice deterioration. To evaluate RLN swelling, the researchers measured the diameter of the nerve with Vernier calipers before and after the lobectomy during each operation. RLN diameter increased 0.58 plus or minus 0.05 mm on average (P less than .001). In patients who had partial thyroidectomy, the greater the RLN swelling, the worse the subjective score (P = .03). This was not the case in the total thyroidectomy patients where involvement of two nerves complicates the interaction, he said.

During follow-up, the investigators came upon a revelatory finding. “With median 8-month follow-up, the self-reported, VDI scores had returned to baseline levels,” Dr. Lee said. “Interestingly, not only did the objective DSI scores show a return to baseline levels, but it exceeded the baseline levels, meaning the voice had scored better after surgery than before.” However, he noted only 13 patients completed the follow-up.

“Voice change post-thyroidectomy without recurrent laryngeal nerve injury is a complex phenomenon and is likely multifactorial, and we only looked at two of those factors: the extent of surgery and the gradient of recurrent laryngeal nerve injury with nerve edema as a surrogate,” Dr. Lee said. Future studies should evaluate other factors, including the role of the external branch of the superior laryngeal nerve and patient factors such as diabetes or smoking, he said.

Dr. Lee and his coauthors had no disclosures.

JACKSONVILLE, FLA. – Patients who report receiving and using materials to help them prepare for surgery and its aftermath are less likely to be readmitted, according to results of a large surgical patient survey.

Readmissions after surgery have become anathema to doctors and hospitals as government and commercial payers ratchet up penalties, but a study presented at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress has found that giving patients written instructions, handouts, and videos and directing them to multimedia and online sources can reduce the risk of readmission after surgery by about two-thirds.

Dr. Luke Martin, a general surgery resident at the University of Utah, Salt Lake City, presented results from a nationwide online survey of 1,917 people who either had surgery in the past year or were relatives or caregivers of someone who did.

“We found a direct relationship between the quantity of resources used and the patient-reported feelings of preparedness,” Dr. Martin said. “We found that feeling unprepared or using no resources was associated with an increased 30-day risk of readmission.”

The study analyzed respondents’ feelings of preparedness before surgery and after surgery but before discharge. Those who felt prepared before surgery had a 30-day readmission rate of 8% vs. 23% for those who did not feel prepared. Rates were similar for those who felt prepared after surgery and those who felt unprepared: 9% vs. 23%. The overall readmission rate of 10% “is in line with expected results,” Dr. Martin said. “Using any resource was associated with a 10% rate of readmission, whereas using no resources was associated with a 31% rate of 30-day readmission,” Dr. Martin said.

“The bottom line is that health information resources have not been well studied in surgical patients, and no matter what types of resources we provide patients, sometimes they go out and find their own health information resources and supplements,” Dr. Martin said.

Overall, 64% of respondents said they felt very prepared before and after surgery and before leaving the hospital; 8% felt very unprepared before their operations, and 4% felt that way before leaving the hospital.

Patients who felt prepared were most likely to report being given multiple health information resources before surgery (97% vs. 79%, P less than .001) and before leaving the hospital (91% vs. 85%, P = .02). Resources included face-to-face meetings, written instructions, Internet sites, videos, and smartphone applications.

Patients who reported receiving one or more resources before surgery had rates of feeling prepared exceeding 90%. Those who said they had received three or more resources had almost universal rates of feeling prepared. On the other hand, only about 60% of patients who claimed they did not receive resources before their operations felt prepared.

The researchers also looked at whether survey respondents reported that they actually utilized the resources they were given before their operations or if they sought out resources on their own.

“We found that the very commonly provided written instructions are used by patients less than half the time, 41%, vs. a 90% rate of having them provided,” Dr. Martin said. The converse was true of utilization of Internet resources; only 17% of respondents said they were provided with Internet resources, but 45% said they utilized them.

“We should as providers ensure access to more resources because patients who use more resources or are provided with more resources feel more prepared to transition after surgical procedures, and perhaps we should personalize resources to patients’ preferences, learning styles, and levels of health literacy so that we can ensure they feel prepared to transition before and after their surgical procedure,” Dr. Martin said.

 During the discussion, Dr. Dawn Elfenbein of the University of California, Irvine, cautioned against using quantity of information as the only measure. “We give our patients written instructions and websites, and they say they actually don’t use the information because we give them too much and it needs to be better organized,” she said. ”Sometimes accessibility is part of the issue, and quality is also important.”

Dr. Matthew Corriere of Wake Forest University, Winston-Salem, N.C., had another take on patient preparation for surgery. “I think those patients who do not have Internet access are a real goldmine for readmission,” he said.

Dr. Martin and coauthors had no financial relationships to disclose.

JACKSONVILLE, FLA. – Patients who report receiving and using materials to help them prepare for surgery and its aftermath are less likely to be readmitted, according to results of a large surgical patient survey.

Readmissions after surgery have become anathema to doctors and hospitals as government and commercial payers ratchet up penalties, but a study presented at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress has found that giving patients written instructions, handouts, and videos and directing them to multimedia and online sources can reduce the risk of readmission after surgery by about two-thirds.

Dr. Luke Martin, a general surgery resident at the University of Utah, Salt Lake City, presented results from a nationwide online survey of 1,917 people who either had surgery in the past year or were relatives or caregivers of someone who did.

“We found a direct relationship between the quantity of resources used and the patient-reported feelings of preparedness,” Dr. Martin said. “We found that feeling unprepared or using no resources was associated with an increased 30-day risk of readmission.”

The study analyzed respondents’ feelings of preparedness before surgery and after surgery but before discharge. Those who felt prepared before surgery had a 30-day readmission rate of 8% vs. 23% for those who did not feel prepared. Rates were similar for those who felt prepared after surgery and those who felt unprepared: 9% vs. 23%. The overall readmission rate of 10% “is in line with expected results,” Dr. Martin said. “Using any resource was associated with a 10% rate of readmission, whereas using no resources was associated with a 31% rate of 30-day readmission,” Dr. Martin said.

“The bottom line is that health information resources have not been well studied in surgical patients, and no matter what types of resources we provide patients, sometimes they go out and find their own health information resources and supplements,” Dr. Martin said.

Overall, 64% of respondents said they felt very prepared before and after surgery and before leaving the hospital; 8% felt very unprepared before their operations, and 4% felt that way before leaving the hospital.

Patients who felt prepared were most likely to report being given multiple health information resources before surgery (97% vs. 79%, P less than .001) and before leaving the hospital (91% vs. 85%, P = .02). Resources included face-to-face meetings, written instructions, Internet sites, videos, and smartphone applications.

Patients who reported receiving one or more resources before surgery had rates of feeling prepared exceeding 90%. Those who said they had received three or more resources had almost universal rates of feeling prepared. On the other hand, only about 60% of patients who claimed they did not receive resources before their operations felt prepared.

The researchers also looked at whether survey respondents reported that they actually utilized the resources they were given before their operations or if they sought out resources on their own.

“We found that the very commonly provided written instructions are used by patients less than half the time, 41%, vs. a 90% rate of having them provided,” Dr. Martin said. The converse was true of utilization of Internet resources; only 17% of respondents said they were provided with Internet resources, but 45% said they utilized them.

“We should as providers ensure access to more resources because patients who use more resources or are provided with more resources feel more prepared to transition after surgical procedures, and perhaps we should personalize resources to patients’ preferences, learning styles, and levels of health literacy so that we can ensure they feel prepared to transition before and after their surgical procedure,” Dr. Martin said.

 During the discussion, Dr. Dawn Elfenbein of the University of California, Irvine, cautioned against using quantity of information as the only measure. “We give our patients written instructions and websites, and they say they actually don’t use the information because we give them too much and it needs to be better organized,” she said. ”Sometimes accessibility is part of the issue, and quality is also important.”

Dr. Matthew Corriere of Wake Forest University, Winston-Salem, N.C., had another take on patient preparation for surgery. “I think those patients who do not have Internet access are a real goldmine for readmission,” he said.

Dr. Martin and coauthors had no financial relationships to disclose.

JACKSONVILLE, FLA. – Patients who report receiving and using materials to help them prepare for surgery and its aftermath are less likely to be readmitted, according to results of a large surgical patient survey.

Readmissions after surgery have become anathema to doctors and hospitals as government and commercial payers ratchet up penalties, but a study presented at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress has found that giving patients written instructions, handouts, and videos and directing them to multimedia and online sources can reduce the risk of readmission after surgery by about two-thirds.

Dr. Luke Martin, a general surgery resident at the University of Utah, Salt Lake City, presented results from a nationwide online survey of 1,917 people who either had surgery in the past year or were relatives or caregivers of someone who did.

“We found a direct relationship between the quantity of resources used and the patient-reported feelings of preparedness,” Dr. Martin said. “We found that feeling unprepared or using no resources was associated with an increased 30-day risk of readmission.”

The study analyzed respondents’ feelings of preparedness before surgery and after surgery but before discharge. Those who felt prepared before surgery had a 30-day readmission rate of 8% vs. 23% for those who did not feel prepared. Rates were similar for those who felt prepared after surgery and those who felt unprepared: 9% vs. 23%. The overall readmission rate of 10% “is in line with expected results,” Dr. Martin said. “Using any resource was associated with a 10% rate of readmission, whereas using no resources was associated with a 31% rate of 30-day readmission,” Dr. Martin said.

“The bottom line is that health information resources have not been well studied in surgical patients, and no matter what types of resources we provide patients, sometimes they go out and find their own health information resources and supplements,” Dr. Martin said.

Overall, 64% of respondents said they felt very prepared before and after surgery and before leaving the hospital; 8% felt very unprepared before their operations, and 4% felt that way before leaving the hospital.

Patients who felt prepared were most likely to report being given multiple health information resources before surgery (97% vs. 79%, P less than .001) and before leaving the hospital (91% vs. 85%, P = .02). Resources included face-to-face meetings, written instructions, Internet sites, videos, and smartphone applications.

Patients who reported receiving one or more resources before surgery had rates of feeling prepared exceeding 90%. Those who said they had received three or more resources had almost universal rates of feeling prepared. On the other hand, only about 60% of patients who claimed they did not receive resources before their operations felt prepared.

The researchers also looked at whether survey respondents reported that they actually utilized the resources they were given before their operations or if they sought out resources on their own.

“We found that the very commonly provided written instructions are used by patients less than half the time, 41%, vs. a 90% rate of having them provided,” Dr. Martin said. The converse was true of utilization of Internet resources; only 17% of respondents said they were provided with Internet resources, but 45% said they utilized them.

“We should as providers ensure access to more resources because patients who use more resources or are provided with more resources feel more prepared to transition after surgical procedures, and perhaps we should personalize resources to patients’ preferences, learning styles, and levels of health literacy so that we can ensure they feel prepared to transition before and after their surgical procedure,” Dr. Martin said.

 During the discussion, Dr. Dawn Elfenbein of the University of California, Irvine, cautioned against using quantity of information as the only measure. “We give our patients written instructions and websites, and they say they actually don’t use the information because we give them too much and it needs to be better organized,” she said. ”Sometimes accessibility is part of the issue, and quality is also important.”

Dr. Matthew Corriere of Wake Forest University, Winston-Salem, N.C., had another take on patient preparation for surgery. “I think those patients who do not have Internet access are a real goldmine for readmission,” he said.

Dr. Martin and coauthors had no financial relationships to disclose.

JACKSONVILLE, FLA. – When an admired surgical resident from Stanford (Calif.) University took his own life during his fellowship within 4 months of completing his residency, it sent a wake-up call to the residency program directors that burnout of surgical and medical residents was real and that something had to be done about it.

So Stanford launched a programmed approach to address resident burnout that includes group counseling, retreats, and even a fully stocked refrigerator accessible 24 hours a day, and found that after 3 years residents reported feeling more “in balance” than they did before the program started, said Dr. Claudia Mueller, a pediatric surgeon at Stanford, who presented a poster on the program at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.

The surgery department at Stanford has charted the progress of the program to address burnout among surgical residents. The effort started with the creation of a committee at the behest of Dr. Ralph Greco, former Stanford residency program director and study coauthor. “This group was intentionally resident driven so that we could figure out how best to look at four concepts of wellness – psychological, physical, social, and professional – from the resident perspective, because all four areas are necessary,” Dr. Mueller said.

Components of the program include outside group activities, group sessions on a 4- to 6-week schedule with a psychologist who is also available for individual sessions, and wellness visits to doctors.

To evaluate the program, the study authors had the surgical residents complete two different surveys, the Life Balance survey and the Causes of Stress survey, at separate times during 2013-2015. In the first assessment, only 5 of 25 residents surveyed achieved scores indicating their lives were in balance. “We knew that something was off,” Dr. Mueller said.

First-year residents were more likely to report feeling in balance than were more senior colleagues, Dr. Mueller said. “After about 3 years, we looked at how residents were doing in terms of balance, and what we found is that there have been some improvements, although not as many as we would like,” she said. “Junior residents in particular seemed to have shown some improvements in their overall balance.”

The concept is reproducible at other institutions, Dr. Mueller said. Dr. Ellen Morrow, a former Stanford resident, has started a similar program at the University of Utah, and other residency managers have approached Stanford for advice. Dr. Mueller said she believes that one key to the program is the involvement of residents. “It has to be what the residents want, not what we think they want,” she said.

“Our program came out of a very tragic event,” Dr. Mueller said. “We’re trying obviously not only to prevent a tragedy like that from happening again, but to also improve the lives of residents overall. The burnout is everywhere.”

Dr. Mueller said she had no financial relationships to disclose.

JACKSONVILLE, FLA. – When an admired surgical resident from Stanford (Calif.) University took his own life during his fellowship within 4 months of completing his residency, it sent a wake-up call to the residency program directors that burnout of surgical and medical residents was real and that something had to be done about it.

So Stanford launched a programmed approach to address resident burnout that includes group counseling, retreats, and even a fully stocked refrigerator accessible 24 hours a day, and found that after 3 years residents reported feeling more “in balance” than they did before the program started, said Dr. Claudia Mueller, a pediatric surgeon at Stanford, who presented a poster on the program at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.

The surgery department at Stanford has charted the progress of the program to address burnout among surgical residents. The effort started with the creation of a committee at the behest of Dr. Ralph Greco, former Stanford residency program director and study coauthor. “This group was intentionally resident driven so that we could figure out how best to look at four concepts of wellness – psychological, physical, social, and professional – from the resident perspective, because all four areas are necessary,” Dr. Mueller said.

Components of the program include outside group activities, group sessions on a 4- to 6-week schedule with a psychologist who is also available for individual sessions, and wellness visits to doctors.

To evaluate the program, the study authors had the surgical residents complete two different surveys, the Life Balance survey and the Causes of Stress survey, at separate times during 2013-2015. In the first assessment, only 5 of 25 residents surveyed achieved scores indicating their lives were in balance. “We knew that something was off,” Dr. Mueller said.

First-year residents were more likely to report feeling in balance than were more senior colleagues, Dr. Mueller said. “After about 3 years, we looked at how residents were doing in terms of balance, and what we found is that there have been some improvements, although not as many as we would like,” she said. “Junior residents in particular seemed to have shown some improvements in their overall balance.”

The concept is reproducible at other institutions, Dr. Mueller said. Dr. Ellen Morrow, a former Stanford resident, has started a similar program at the University of Utah, and other residency managers have approached Stanford for advice. Dr. Mueller said she believes that one key to the program is the involvement of residents. “It has to be what the residents want, not what we think they want,” she said.

“Our program came out of a very tragic event,” Dr. Mueller said. “We’re trying obviously not only to prevent a tragedy like that from happening again, but to also improve the lives of residents overall. The burnout is everywhere.”

Dr. Mueller said she had no financial relationships to disclose.

JACKSONVILLE, FLA. – When an admired surgical resident from Stanford (Calif.) University took his own life during his fellowship within 4 months of completing his residency, it sent a wake-up call to the residency program directors that burnout of surgical and medical residents was real and that something had to be done about it.

So Stanford launched a programmed approach to address resident burnout that includes group counseling, retreats, and even a fully stocked refrigerator accessible 24 hours a day, and found that after 3 years residents reported feeling more “in balance” than they did before the program started, said Dr. Claudia Mueller, a pediatric surgeon at Stanford, who presented a poster on the program at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.

The surgery department at Stanford has charted the progress of the program to address burnout among surgical residents. The effort started with the creation of a committee at the behest of Dr. Ralph Greco, former Stanford residency program director and study coauthor. “This group was intentionally resident driven so that we could figure out how best to look at four concepts of wellness – psychological, physical, social, and professional – from the resident perspective, because all four areas are necessary,” Dr. Mueller said.

Components of the program include outside group activities, group sessions on a 4- to 6-week schedule with a psychologist who is also available for individual sessions, and wellness visits to doctors.

To evaluate the program, the study authors had the surgical residents complete two different surveys, the Life Balance survey and the Causes of Stress survey, at separate times during 2013-2015. In the first assessment, only 5 of 25 residents surveyed achieved scores indicating their lives were in balance. “We knew that something was off,” Dr. Mueller said.

First-year residents were more likely to report feeling in balance than were more senior colleagues, Dr. Mueller said. “After about 3 years, we looked at how residents were doing in terms of balance, and what we found is that there have been some improvements, although not as many as we would like,” she said. “Junior residents in particular seemed to have shown some improvements in their overall balance.”

The concept is reproducible at other institutions, Dr. Mueller said. Dr. Ellen Morrow, a former Stanford resident, has started a similar program at the University of Utah, and other residency managers have approached Stanford for advice. Dr. Mueller said she believes that one key to the program is the involvement of residents. “It has to be what the residents want, not what we think they want,” she said.

“Our program came out of a very tragic event,” Dr. Mueller said. “We’re trying obviously not only to prevent a tragedy like that from happening again, but to also improve the lives of residents overall. The burnout is everywhere.”

Dr. Mueller said she had no financial relationships to disclose.