Introduction Unstructured clinical data, including operative reports and progress notes, contain critical surgical information that is often absent from structured electronic health record fields. Manual abstraction is time-consuming at scale. Natural language processing (NLP) enables automated extraction of clinically meaningful information to support data-driven perioperative care. Methods We conducted a narrative review of NLP applications in surgical and trauma care. Applications were evaluated across outcome prediction, postoperative complication detection, automated registry generation, documentation quality assessment, and identification of high-risk patient phenotypes, along with key implementation and data-governance considerations. Results NLP approaches demonstrated strong performance in extracting granular clinical variables and identifying postoperative complications from unstructured text. Transformer-based models, which process entire sentences at once using self-attention to understand word relationships and context, improve recognition of contextual clinical language, supporting more accurate risk stratification and quality measurement. Key challenges include documentation variability, limited generalizability across institutions, algorithmic bias, and limited interpretability. Conclusions NLP, particularly transformer-based approaches, provides a scalable strategy to leverage unstructured clinical text for surgical research and quality improvement. Integration into clinical workflows has the potential to enhance perioperative outcomes and precision surgery, contingent on rigorous validation and responsible implementation.

SCIP measures included appropriate discontinuation of antimicrobial prophylaxis (AbxPPx) within 48 hours for cardiac surgeries. Metrics were manually collected and publicly reported; over time, the program was associated with compliance rates > 95% in Veterans Health Administration (VHA) hospitals. Manual review is expensive and SCIP was discontinued in 2015. The objective of this study was to measure compliance with SCIP INF-3, timely discontinuation of AbxPPx, in VHA cardiac surgery to assess whether compliance was sustained after the active reporting period.Figure 1.Timing of SCIP INF-3 compliance, discordance, and exclusion criteria for cardiac surgery algorithmFigure 2.Incidence of SCIP INF-3 compliance (appropriate discontinuation of post-op antibiotics) in EPRP-reviewed data (n=33,036, 2006-2015) vs. algorithm among eligible CDW cardiac surgeries (n=56,244, 2006-2019) This retrospective cohort study of cardiac surgeries from 2006 -2019, included data from the Corporate Data Warehouse (CDW) and manually reviewed AbxPPx compliance data from VHA External Peer Review Program (EPRP) from 2006-15. CDW cardiac surgeries were merged with EPRP data to develop a robust electronic algorithm to measure SCIP INF-3 compliance (Fig 1). The algorithm was applied to cases from 2011-2019 to assess whether SCIP INF-3 compliance was ≥ 95% after public reporting was discontinued. Sustainability was assessed by performing an interrupted time-series analysis with 2015 SCIP discontinuation as the interruption. The Poisson regression model with time offset estimated change in slope immediately at discontinuation and annually over time in the pre- and post-SCIP periods, controlling for facility random effects.Figure 3.Facility-level SCIP INF-3 compliance rates during SCIP active reporting and after discontinuation SCIP INF-3 compliance as assessed by EPRP (98.4%) and the electronic algorithm (97.7%) are presented in Fig 2. Among eligible cardiac surgeries performed at 39 hospitals, AbxPPx compliance rates did not change from 2011-2019; however, the time series model identified a slight and significant dip in compliance the year that SCIP was discontinued. Individual facilities were relatively consistent in compliance rates during SCIP active reporting and after discontinuation, suggesting stable practices over time. In some cases, facility-level SCIP INF-3 compliance improved over time (Fig 3). SCIP sustainably improved AbxPPx use for major cardiac surgeries. Future work should evaluate ongoing compliance other specialties and whether AbxPPx guidelines issued during the SCIP reporting period were broadly implemented. Westyn Branch-Elliman, MD, MMSc, DLA Piper, LLC/Medtronic: Advisor/Consultant|DLA Piper, LLC/Medtronic: Expert Testimony|Shiongi: Advisor/Consultant

OBJECTIVE:To review the current state of research training during surgical residency and make recommendations commensurate with current surgical training and academic environment. BACKGROUND:Research training has been a mainstay of academic surgical programs, yet the scientific disciplines have evolved significantly from the traditional years of bench research. It is time to reconsider how research training should prepare surgeons for future academic practice and ensure the foundational knowledge of research evidence. METHODS:As part of the Blue Ribbon Committee II, a research subcommittee was tasked to make recommendations on research training during surgical residency. Our 8-member panel brought diverse perspectives on the roles and goals of research training. We also sought input from a convenience sample of current and recent surgical residents on the impact of research training during their residency. RESULTS:We identified a lack of a common framework and foundational research training for all surgical residents. Participation in dedicated years of scholarly activity helped trainees meet several professional and personal goals. The lack of an integrated, dedicated research track may dissuade some medical school graduates from pursuing surgery. CONCLUSIONS:We recommend incorporating a minimum standard for all trainees and flexibility in dedicated scholarly training to meet the needs of future academic surgeons.

Background: Cancer is a leading cause of death in people experiencing homelessness, who are more commonly diagnosed with late-stage disease and have poorer survival after diagnosis than housed. Objective: To characterize the incidence and timeliness of colorectal and breast cancer screening in a national sample of Veterans. Design: Retrospective, matched cohort study from 2011 to 2021 in a national sample of Veterans receiving care from the Veterans Health Administration (VA). Participants: Each Veteran experiencing homelessness was matched to three housed Veterans with the same age, gender, clinic location, and month and year of outpatient clinic appointment. Exposure: We classified Veterans as homeless if they had any homeless indicator at the matched clinic visit or in the 12 months prior and all others as housed. Main Measures: Our primary outcomes were being up to date on screening, receiving a biopsy following a positive screen and timeliness of biopsy. We assessed the association between housing status and our outcomes using conditional Poisson regression models with generalized estimating equations, adjusting for race, ethnicity, marital status, Charlson Comorbidity Index, smoking status, and mental health comorbidities. Key Results: Our sample included 2,580,640 Veterans, with 1,935,480 housed and 645,160 experiencing homelessness. Patients experiencing homelessness had a 16% lower adjusted incidence rate ratio (aIRR) of being up to date with colorectal cancer screening when compared to housed (aIRR 0.84, 95%CI 0.83-0.84; p<0.001) and a 13% lower aIRR for breast cancer (aIRR 0.87, 95%CI 0.86-0.88; p<0.001). Following a positive stool-based test, patients experiencing homelessness had a 12% lower aIRR of undergoing diagnostic colonoscopy compared to housed (aIRR 0.88, 95%CI 0.84-0.92; p<0.001). Time to biopsy was similar between groups for both cancer types. Conclusions: Veterans experiencing homelessness were less commonly screened for cancer than a matched housed cohort. However, screening rates in this group were higher than in non-Veteran homeless populations. The VA system may offer insights into providing preventative care for this population.

BACKGROUND:A Joint Commission national program, the surgical care improvement project (SCIP), supported the adoption of evidence-based peri-operative antimicrobial use practices, including administration of antimicrobials prior to incision and early discontinuation after skin closure. With high compliance, in 2015, the public reporting requirement that provided external pressure to support practice improvements was discontinued. Since discontinuation, few studies have assessed the sustainment of best antimicrobial use practices and what procedures were developed to maintain improvements within facilities. OBJECTIVE:The aim of this study was to measure perceptions among antimicrobial stewardship experts about which policies and practices have been important and effective for sustainment. DESIGN:A 15-min survey was administered to the Society for Hhealthcare Epidemiology in America (SHEA) research network over the summer of 2023. The survey included questions about different SCIP measures such as prophylactic antibiotic use pre and post-surgery and about local policies and procedures that were implemented to support best practices. Simple descriptive statistics were utilized to analyze results. RESULTS:The survey was distributed to 112 members of the SHEA research network, with a 41% response rate. Most respondents perceived high rates of ongoing compliance with both pre- and post-operative prophylaxis guidelines, although ongoing surveillance and measurement is limited. Respondents perceived that the most important internal factors associated with ongoing compliance were electronic order sets, facility policies, time outs, and automatic stop orders. Substantial spread of best practices (eg, to surgical procedures and specialties not covered until the SCIP program) was reported. CONCLUSIONS:Despite discontinuation of mandated reporting, antimicrobial stewards perceived ongoing compliance with SCIP measures. Local policies and procedures implemented to support initial uptake of best practices have supported ongoing sustainment of practice improvements.

PURPOSE:People experiencing homelessness have lower rates of cancer screening than housed people, contributing to later stages at cancer diagnosis and poor outcomes. We examined whether gaining housing increased rates of cancer screening in a cohort of homeless veterans. METHODS:We conducted a retrospective cohort study examining all veterans experiencing homelessness who were eligible for, but not up to date on, colorectal and breast cancer screening from 2011 to 2021. Our exposure was gaining housing in the 24 months after the index clinic visit, conceptualized as a time-varying covariate. Our primary outcome was undergoing breast or colorectal screening in the 24 months after that visit. We performed bivariate analysis and Cox proportional hazards analysis, clustering on the facility level and adjusting for clinical and demographic covariates. RESULTS:Our cohort included 117,619 homeless veterans who were eligible for but not up to date on colorectal cancer screening at their index visit, of whom 57,705 (49.0%) gained housing over 24 months. The cohort included 6,517 homeless veterans who were eligible for but not up to date on breast cancer screening, of whom 3,101 (47.5%) gained housing over 24 months. Compared with peers who remained homeless, veterans who gained housing were more than twice as likely to undergo colorectal cancer screening (adjusted hazard ratio, 2.3; 95% CI, 2.2-2.3; P <.001) and breast cancer screening (adjusted hazard ratio, 2.4; 95% CI, 2.2-2.7; P <.001). CONCLUSIONS:Veterans experiencing homelessness who gain housing have higher rates of cancer screening. This finding supports promotion of housing to improve health outcomes for homeless individuals.

Academic surgical departments must subsidize the research mission, as most funded research does not fully support the faculty effort and true costs of the investigation. Most departments support their research program with the margin from clinical revenue; however, increased pressure on clinical income poses a challenge to this strategy. Philanthropy is an increasingly important revenue source to fund academic missions. The opportunities and challenges of this funding source are discussed in this article.

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Importance Care transition models are structured approaches used to ensure the smooth transfer of patients between health care settings or levels of care, but none currently are tailored to the surgical patient. Tailoring care transition models to the unique needs of surgical patients may lead to significant improvements in surgical outcomes and reduced care fragmentation. The first step to developing surgical care transition models is to understand the surgical discharge process. Objective To map the surgical discharge process in a sample of US hospitals and identify key components and potential challenges specific to a patient's discharge after surgery. Design, Setting, and Participants This qualitative study followed a cognitive task analysis framework conducted between January 1, 2022, and April 1, 2023, in Veterans Health Administration (VHA) hospitals. Observations (n = 16) of discharge from inpatient care after a surgical procedure were conducted in 2 separate VHA surgical units. Interviews (n = 13) were conducted among VHA health care professionals nationwide. Exposure Postoperative hospital discharge. Main Outcomes and Measures Data were coded according to the principles of thematic analysis, and a swim lane process map was developed to represent the study findings. Results At the hospitals in this study, the discharge process observed for a surgical patient involved multidisciplinary coordination across the surgery team, nursing team, case managers, dieticians, social services, occupational and physical therapy, and pharmacy. Important components for a surgical discharge that were not incorporated in the current care transition models included wound care education and supplies; pain control; approvals for nonhome postdischarge locations; and follow-up plans for wounds, ostomies, tubes, and drains at discharge. Potential challenges to the surgical discharge process included social situations (eg, home environment and caregiver availability), team communication issues, and postdischarge care coordination. Conclusions and Relevance These findings suggest that current and ongoing studies of discharge care transitions for a patient after surgery should consider pain control; wounds, ostomies, tubes, and drains; and the impact of challenging social situations and interdisciplinary team coordination on discharge success.

The Norton Festschrift featured tributes

OBJECTIVE:This study aimed to evaluate the association of surgeon self-reported gender on clinical outcomes in contemporary US surgical practice. BACKGROUND:Previous research has suggested that there are potentially improved surgical outcomes for female surgeons, yet the underlying causal path for this association remains unclear. METHODS:Using the Vizient Clinical Database(2016-2021), 39 operations categorized by the CDC's National Healthcare Safety Network were analyzed. The surgeon self-reported gender as the primary exposure. The primary outcome was a composite of in-hospital death, complications, and/or 30-day readmission. Multivariable logistic regression and propensity score matching were used for risk adjustment. RESULTS:The analysis included 4,882,784 patients operated on by 11,955 female surgeons (33% of surgeons performing 21% of procedures) and 23,799 male surgeons (67% of surgeons performing 79% of procedures). Female surgeons were younger (45±9 vs males-53±11 y; P <0.0001) and had lower operative volumes. Unadjusted incidence of the primary outcome was 13.6%(10.7%-female surgeons, 14.3%-male surgeons; P <0.0001). After propensity matching, the primary outcome occurred in 13.0% of patients [12.9%-female, 13.0%-male; OR (M vs. F)=1.02, 95% CI: 1.01-1.03; P =0.001), with female surgeons having small statistical associations with lower mortality and complication rates but not readmissions. Procedure-specific analyses revealed inconsistent or no surgeon-gender associations. CONCLUSIONS:In the largest analysis to date, surgeon self-reported gender had a small statistical, clinically marginal correlation with postoperative outcomes. The variation across surgical specialties and procedures suggests that the association with surgeon gender is unlikely causal for the observed differences in outcomes. Patients should be reassured that surgeon gender alone does not have a clinically meaningful impact on their outcome.

Cancer is a leading cause of death in older unhoused adults. We assessed whether being unhoused, gaining housing, or losing housing in the year after cancer diagnosis is associated with poorer survival compared with being continuously housed. We examined all -cause survival in more than 100,000 veterans diagnosed with lung, colorectal, and breast cancer during the period 2011-20. Five percent were unhoused at the time of diagnosis, of whom 21 percent gained housing over the next year; 1 percent of veterans housed at the time of diagnosis lost housing. Continuously unhoused veterans and veterans who lost their housing had poorer survival after lung and colorectal cancer diagnosis compared with those who were continuously housed. There was no survival difference between veterans who gained housing after diagnosis and veterans who were continuously housed. These findings support policies to prevent and end homelessness in people after cancer diagnosis, to improve health outcomes.

Department of Surgery, Stanford University Funding disclosure: none The authors report no conflicts of interest. [email protected]

Dr. Chen, thank you for the great honor of speaking at Dr. Kirby Bland's Festschrift. I want to share leadership lessons that I learned from Dr. Bland from the perspective of working under him, first as a junior faculty member and then in his departmental leadership over my 14 year career at UAB. Being the last speaker, I will likely emphasize and perhaps add levity to comments made by the previous speakers.

Abstract Background The Surgical Care Improvement Project (SCIP) was a national quality improvement program designed to improve peri-operative outcomes. The SCIP Program included several guideline-based antimicrobial stewardship measures, including discontinuation of antibiotics within 48 hours of skin closure for cardiac surgeries (INF-3). INF-3 was retired at the end of 2015; since this time, no systematic tools have been developed to support ongoing quality assessments. Methods We developed a retrospective, national cohort of cardiac surgeries in the national VA healthcare system during the period from 2010-2015 and merged these data with data from the VA External Peer Review Program, which included manually-assessed SCIP metrics, including INF-3. We electronically re-created the SCIP program by mapping exclusion criteria and developing code to assess the duration of post-operative antimicrobial use (Table 1). Among the manually-adjudicated cohort, we then iteratively refined the electronic tool until pre-specified criterion validity were achieved. After development, INF-3 compliance as assessed manually and by the objective informatics tool were compared. Results During the study period, 11,361 cardiac surgeries representing 26 VA facilities met inclusion criteria. The overall estimated compliance rate was 97.7% in the EPRP-reviewed cases (N=11,361) and 95.9% as-assessed by the informatics tool (N=9,561 cases); facility quality rankings using both methods were similar but not exactly the same (Figure 1). Facility-level compliance trends were similar using both measurement methodologies and the correlation between the two measures was high (r=0.69); however, the informatics tool consistently estimated compliance to be approximately 1.9% lower than manually reviewed cases (Figure 2). As estimated by the manual review program, 16 facilities (61.5%) achieved >97% compliance rates versus 9 facilities (34.6%) as estimated by the informatics tool. Figure 2. Facility-Level Compliance with INF-3 as Measured by Manual Review versus via Objective Electronic Tool Conclusion We developed a comprehensive, objective informatics tool for assessing ongoing compliance with SCIP INF-3. The tool can be applied in future investigations to assess the sustainability of practice changes achieved under the SCIP program and to identify areas for future improvement. Disclosures Westyn Branch-Elliman, MD, MMsc, DLA Piper, LLC/Medtronic: Advisor/Consultant|DLA Piper, LLC/Medtronic: Expert Testimony|Gilead Sciences: Grant/Research Support

We define mixed esophageal disease (MED) as a disorder of esophageal structure and/or function that produces variable signs or symptoms, simulating-fully or in part other well-defined esophageal conditions, such as gastroesophageal reflux disease, esophageal motility disorders, or even neoplasia. The central premise of the MED concept is that of an overlap syndrome that incorporates selected clinical, endoscopic, imaging, and functional features that alter the patient’s quality of life and affect natural history, prognosis, and management. In this article, we highlight MED scenarios frequently encountered in medico-surgical practices worldwide, posing new diagnostic and therapeutic challenges. These, in turn, emphasize the need for better understanding and management, aiming towards improved outcomes and prognosis. Since MED has variable and sometimes time-evolving clinical phenotypes, it deserves proper recognition, definition, and collaborative, multidisciplinary approach, be it pharmacologic, endoscopic, or surgical, to optimize therapeutic outcomes, while minimizing iatrogenic complications. In this regard, it is best to define MED early in the process, preferably by teams of clinicians with expertise in managing esophageal diseases. MED is complex enough that is increasingly becoming the subject of virtual, multi-disciplinary, multi-institutional meetings.

Background: Question prompt lists (QPLs) are structured sets of disease-specific questions that enhance patient-physician communication by encouraging patients to ask questions during consultations. Aim: The aim of this study was to develop a preliminary achalasia-specific QPL created by esophageal experts. Methods: The QPL content was derived through a modified Delphi method consisting of 2 rounds. In round 1, experts provided 5 answers to the prompts “What general questions should patients ask when given a new diagnosis of achalasia” and “What questions do I not hear patients asking, but given my expertise, I believe they should be asking?” In round 2, experts rated questions on a 5-point Likert scale. Questions considered “essential” or “important” were accepted into the QPL. Feedback regarding the QPL was obtained in a pilot study wherein patients received the QPL before their consultation and completed surveys afterwards. Results: Nineteen esophageal experts participated in both rounds. Of 148 questions from round 1, 124 (83.8%) were accepted into the QPL. These were further reduced to 56 questions to minimize redundancy. Questions were categorized into 6 themes: “What is achalasia,” “Risks with achalasia,” “Symptom management in achalasia,” “Treatment of achalasia,” “Risk of reflux after treatment,” and “Follow-up after treatment.” Nineteen patients participated in the pilot, most of whom agreed that the QPL was helpful (84.2%) and recommended its wider use (84.2%). Conclusions: This is the first QPL developed specifically for adults with achalasia. Although well-received in a small pilot, follow-up studies will incorporate additional patient feedback to further refine the QPL content and assess its usability, acceptability, and feasibility.

Importance Cancer is a leading cause of death among older people experiencing homelessness. However, the association of housing status with cancer outcomes is not well described.Objective To characterize the diagnosis, treatment, surgical outcomes, and mortality by housing status of patients who receive care from the US Department of Veterans Affairs (VA) health system for colorectal, breast, or lung cancer.Design, Setting, and Participants This retrospective cohort study identified all US veterans diagnosed with lung, colorectal, or breast cancer who received VA care between October 1, 2011, and September 30, 2020. Data analysis was performed from February 13 to May 9, 2023.Exposures Veterans were classified as experiencing homelessness if they had any indicators of homelessness in outpatient visits, clinic reminders, diagnosis codes, or the Homeless Operations Management Evaluation System in the 12 months preceding diagnosis, with no subsequent evidence of stable housing.Main Outcomes and Measures The major outcomes, by cancer type, were as follows: (1) treatment course (eg, stage at diagnosis, time to treatment initiation), (2) surgical outcomes (eg, length of stay, major complications), (3) overall survival by cancer type, and (4) hazard ratios for overall survival in a model adjusted for age at diagnosis, sex, stage at diagnosis, race, ethnicity, marital status, facility location, and comorbidities.Results This study included 109 485 veterans, with a mean (SD) age of 68.5 (9.7) years. Men comprised 92% of the cohort. In terms of race and ethnicity, 18% of veterans were Black, 4% were Hispanic, and 79% were White. A total of 68% of participants had lung cancer, 26% had colorectal cancer, and 6% had breast cancer. There were 5356 veterans (5%) experiencing homelessness, and these individuals more commonly presented with stage IV colorectal cancer than veterans with housing (22% vs 19%; P = .02). Patients experiencing homelessness had longer postoperative lengths of stay for all cancer types, but no differences in other treatment or surgical outcomes were observed. These patients also demonstrated higher rates of all-cause mortality 3 months after diagnosis for lung and colorectal cancers, with adjusted hazard ratios of 1.1 (95% CI, 1.1-1.2) and 1.3 (95% CI, 1.2-1.4) (both P < .001), respectively.Conclusions and Relevance In this large retrospective study of US veterans with cancer, homelessness was associated with later stages at diagnosis for colorectal cancer. Differences in lung and colorectal cancer survival between patients with housing and those experiencing homelessness were present but smaller than observed in other settings. These findings suggest that there may be important systems in the VA that could inform policy to improve oncologic outcomes for patients experiencing homelessness.

OBJECTIVE:Designing practical decision support tools and other health care technology in health services research relies on a clear understanding of the cognitive processes that underlie the use of these tools. Unfortunately, methods to explore cognitive processes are rarely used in health services research. Thus, the objective of this manuscript is to introduce cognitive task analysis (CTA), a family of methods to study cognitive processes involved in completing a task, to a health services research audience. This methods article describes CTA procedures, proposes a framework for their use in health services research studies, and provides an example of its application in a pilot study.DATA SOURCES AND STUDY SETTING:Observations and interviews of health care providers involved in discharge planning at six hospitals in the Veterans Health Administration.STUDY DESIGN:Qualitative study of discharge planning using CTA.DATA COLLECTION/EXTRACTION METHODS:Data were collected from structured observations and semi-structured interviews using the Critical Decision Method and analyzed using thematic analysis.PRINCIPAL FINDINGS:We developed an adaptation of CTA that could be used in a clinical environment to describe clinical decision-making and other cognitive processes. The adapted CTA framework guides the user through four steps: (1) Planning, (2) Environmental Analysis, (3) Knowledge Elicitation, and (4) Analyses and Results. This adapted CTA framework provides an iterative and systematic approach to identifying and describing the knowledge, expertise, thought processes, procedures, actors, goals, and mental strategies that underlie completing a clinical task.CONCLUSIONS:A better understanding of the cognitive processes that underly clinical tasks is key to developing health care technology and decision-support tools that will have a meaningful impact on processes of care and patient outcomes. Our adapted framework offers a more rigorous and detailed method for identifying task-related cognitive processes in implementation studies and quality improvement. Our adaptation of this underutilized qualitative research method may be helpful to other researchers and inform future research in health services research.