Boards, Advisory Committees, Professional Organizations
Global Health Postdoctoral Affiliate, Center for Innovation and Global Health (2023 - Present)
Joseph Shrager, Postdoctoral Faculty Sponsor
Usability of ENTRUST as an Assessment Tool for Entrustable Professional Activities (EPAs): A Mixed Methods Analysis.
Journal of surgical education
As the American Board of Surgery transitions to a competency-based model of surgical education centered upon entrustable professional activities (EPAs), there is a growing need for objective tools to determine readiness for entrustment. This study evaluates the usability of ENTRUST, an innovative virtual patient simulation platform to assess surgical trainees' decision-making skills in preoperative, intra-operative, and post-operative settings.This is a mixed-methods analysis of the usability of the ENTRUST platform. Quantitative data was collected using the system usability scale (SUS) and Likert responses. Analysis was performed with descriptive statistics, bivariate analysis, and multivariable linear regression. Qualitative analysis of open-ended responses was performed using the Nielsen-Shneiderman Heuristics framework.This study was conducted at an academic institution in a proctored exam setting.The analysis includes n = 47 (PGY 1-5) surgical residents who completed an online usability survey following the ENTRUST Inguinal Hernia EPA Assessment.The ENTRUST platform had a median SUS score of 82.5. On bivariate and multivariate analyses, there were no significant differences between usability based on demographic characteristics (all p > 0.05), and SUS score was independent of ENTRUST performance (r = 0.198, p = 0.18). Most participants agreed that the clinical workup of the patient was engaging (91.5%) and felt realistic (85.1%). The most frequent heuristics represented in the qualitative analysis included feedback, visibility, match, and control. Additional themes of educational value, enjoyment, and ease-of-use highlighted participants' perspectives on the usability of ENTRUST.ENTRUST demonstrates high usability in this population. Usability was independent of ENTRUST score performance and there were no differences in usability identified in this analysis based on demographic subgroups. Qualitative analysis highlighted the acceptability of ENTRUST and will inform ongoing development of the platform. The ENTRUST platform holds potential as a tool for the assessment of EPAs in surgical residency programs.
View details for DOI 10.1016/j.jsurg.2023.09.001
View details for PubMedID 37821350
Achieving global surgical excellence: an evidence-based framework to guide surgical quality improvement programs in low and middle income countries.
Frontiers in health services
2023; 3: 1096144
There is a lack of evidence-based guidelines for enhancing global surgical care delivery. We propose a set of recommendations to serve as a framework to guide surgical quality improvement and scale-up initiatives in low and middle income countries (LMICs).From January-December 2019, we reviewed the available literature and their application toward LMIC settings. The first initiative was the establishment of Best Practices Recommendations intended to summarize best-level evidence around quality improvement processes that have shown to decrease morbidity and mortality in LMICs. The GRADE level of evidence and strength of the recommendation were assigned in accordance with the WHO handbook for guidelines development. The second initiative was the scale-up of principles and practices by establishing international expert consensus on the optimal organization of surgical services in LMICs using a modified Delphi methodology.Recommendations for three topic areas were established: reducing surgical site infections, improving quality of trauma systems, and interventions to reduce maternal and perinatal mortality. 27 studies were included in a quantitative synthesis and meta-analysis for interventions reducing surgical site infections, 27 studies for interventions improving the quality of trauma systems, and 14 studies for interventions reducing maternal and perinatal mortality. Using Delphi methodology, an international expert panel established consensus that district hospitals should place the highest priority on developing surgical services for low complexity, high volume conditions. At the national level, emergency and essential surgical care should be integrated within national Universal Health Coverage frameworks.This project fills a critical cap in the rapidly developing field of global surgery: gathering evidence-based, practical, and cost-effective solutions that will serve as a guide for the efficient planning and allocation of resources necessary to promote quality and safe essential surgical services in LMICs.
View details for DOI 10.3389/frhs.2023.1096144
View details for PubMedID 37609518
View details for PubMedCentralID PMC10441221
Intraoperative Molecular Imaging of Lung Cancer.
Thoracic surgery clinics
2023; 33 (3): 227-232
Intraoperative molecular imaging innovations have been propelled by the development of fluorescent contrast agents that specifically target tumor tissues and advanced camera systems that can detect the specified fluorescence. The most promising agent to date is OTL38, a targeted and near-infrared agent that was recently approved by the Food and Drug Administration for intraoperative imaging for lung cancer.
View details for DOI 10.1016/j.thorsurg.2023.04.013
View details for PubMedID 37414478
The impact of neoadjuvant immunotherapy on perioperative outcomes and survival after esophagectomy for esophageal cancer.
2023; 14: 547-560
Objective: Immunotherapy for esophageal cancer is relatively novel but increasingly used. This study evaluated the early use of immunotherapy as an adjunct to neoadjuvant chemoradiotherapy before esophagectomy for locally advanced disease.Methods: Perioperative morbidity (composite of mortality, hospitalization ≥21days, or readmission) and survival of patients with locally advanced (cT3N0M0, cT1-3N + M0) distal esophageal cancer in the National Cancer Database from 2013 to 2020 who underwent neoadjuvant immunotherapy plus chemoradiotherapy or chemoradiotherapy alone followed by esophagectomy were evaluated using logistic regression, Kaplan-Meier curves, Cox proportional hazards methods, and propensity-matched analysis.Results: Immunotherapy was used in 165 (1.6%) of 10,348 patients. Younger age (odds ratio, 0.66; 95% confidence interval, 0.53-0.81; P<.001) predicted immunotherapy use, which slightly delayed time from diagnosis to surgery versus chemoradiation alone (immunotherapy 148 [interquartile range, 128-177] days vs chemoradiation 138 [interquartile range, 120-162] days, P<.001). There were no statistically significant differences between the immunotherapy and chemoradiation groups for the composite major morbidity index (14.5% [24/165] vs 15.6% [1584/10,183], P=.8). Immunotherapy was associated with a significant improvement in median overall survival (69.1months vs 56.3months, P=.005) and 3-year overall survival in univariate analysis (65.6% [95% confidence interval, 57.7-74.5] vs 55.0% [53.9-56.1], P=.005), and independently predicted improved survival in multivariable analysis (hazard ratio 0.68 [95% confidence interval, 0.52-0.89], P=.006). Propensity-matched analysis also showed that immunotherapy use was not associated with increased surgical morbidity (P=.5) but was associated with improved survival (P=.047).Conclusions: Neoadjuvant immunotherapy use before esophagectomy for locally advanced esophageal cancer did not lead to worse perioperative outcomes and shows promising results on midterm survival.
View details for DOI 10.1016/j.xjon.2023.03.015
View details for PubMedID 37425457
Surgical Management of Esophageal Perforation: Examining Trends in a Multi-Institutional Cohort.
Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract
Esophageal perforations historically are associated with significant morbidity and mortality and generally require emergent intervention. The influence of improved diagnostic and therapeutic modalities available in recent years on management has not been examined. This study examined the surgical treatments and outcomes of a modern cohort.Patients with esophageal perforation management in the 2005-2020 American College of Surgeons National Surgical Quality Improvement Program database were stratified into three eras (2005-2009, 2010-2014, and 2015-2020). Surgical management was classified as primary repair, resection, diversion, or drainage alone based on procedure codes. The distribution of procedure use, morbidity, and mortality across eras was examined.Surgical management of 378 identified patients was primary repair (n=193,51%), drainage (n=89,24%), resection (n=70,18%), and diversion (n=26,7%). Thirty-day mortality in the cohort was 9.5% (n=36/378) and 268 patients (71%) had at least one complication. The median length of stay was 15 days. Both morbidity (Era 1 65% [n=42/60] versus Era 2 69% [n=92/131] versus Era 3 72% [n=135/187], p=0.3) and mortality (Era 1 11% [n=7/65] versus Era 2 9% [n=12/131] versus Era 3 10% [n=19/187], p=0.9) did not change significantly over the three defined eras. Treatment over time evolved such that primary repair was more frequently utilized (43% in Era 1 to 51% in Era 3) while diversion was less often performed (13% in Era 1 to 7% in Era 3) (p=0.009).Esophageal perforation management in recent years uses diversion less often but remains associated with significant morbidity and mortality.
View details for DOI 10.1007/s11605-023-05700-1
View details for PubMedID 37165161
View details for PubMedCentralID 7330325
- Consequences of a Failed Nonoperative Approach in Paraesophageal Hernia Management. The Annals of thoracic surgery 2023
- ASO Visual Abstract: Impact of Delaying Surgery After Chemoradiation on Outcomes for Locally Advanced Esophageal Squamous Cell Carcinoma. Annals of surgical oncology 2023
The Impact of Age and Need for Emergent Surgery in Paraesophageal Hernia Repair Outcomes.
The Annals of thoracic surgery
Observation of paraesophageal hernias (PEH) may lead to emergent surgery for hernia-related complications. This study evaluated urgent/emergent repair outcomes to quantify the possible sequelae of failed conservative PEH management.The impact of operative status (Elective vs. Urgent/Emergent) on perioperative mortality or major morbidity for patients who underwent hiatal hernia repair for a paraesophageal hernia diagnosis from 2012-2021 in the Society of Thoracic Surgery General Thoracic Surgery Database was evaluated with multivariable logistic regression models.Overall, 2,082 (10.9%) of 19,122 PEH patients underwent Urgent/Emergent repair. Non-elective surgery patients were significantly older than elective surgery patients (median age 73 years [IQR 63-82] versus 66 [58-74]) and had a lower preoperative performance score (p<0.001). Non-elective surgeries were more likely to be done through the chest or via laparotomy rather than via laparoscopy (20% versus 11.4%, p<0.001) and were associated with longer hospitalizations (4 days vs 2, p<0.001), higher operative mortality (4.5% vs 0.6%, p<0.001), and higher major morbidity (27% versus 5.5%, p<0.001). Non-elective surgery was a significant independent predictor of major morbidity in multivariable analysis (odds ratio 2.06, p<0.001). Patients over the age of 80 had higher operative mortality (4.3% vs 0.6%, p<0.001) and major morbidity (19% vs 6.1%, p<0.001) than younger patients overall, and more often had non-elective surgery (26% vs 8.6%, p<0.001) CONCLUSIONS: The operative morbidity of PEH repair is significantly increased when surgery is non-elective, particularly for older patients. These results can inform the potential consequences of choosing watchful waiting versus elective PEH repair.
View details for DOI 10.1016/j.athoracsur.2023.01.017
View details for PubMedID 36702291
- ASO Author Reflections: Timing of Surgery and Chemoradiation for Esophageal Squamous Cell Carcinoma. Annals of surgical oncology 2023
Impact of Delaying Surgery After Chemoradiation on Outcomes for Locally Advanced Esophageal Squamous Cell Carcinoma.
Annals of surgical oncology
BACKGROUND: Performing selective esophagectomy for locally advanced squamous cell carcinoma may spare patients morbidity, but delayed surgery may infer higher risks. This study evaluated the impact of length of time between chemoradiation and esophagectomy on perioperative outcomes and long-term survival.METHODS: The impact of surgical timing, stratified by surgery performed < 180 and ≥ 180 days from starting radiation, on perioperative outcomes and survival in patients treated with chemoradiation and esophagectomy for cT1N + M0 and cT2-4, any N, M0 squamous cell carcinoma of the mid-distal esophagus in the National Cancer Database (2006-2016) was evaluated with logistic regression, Kaplan-Meier curves, Cox proportional-hazards methods, and propensity-matched analysis.RESULTS: Median time between starting radiation and esophagectomy in 1641 patients was 93 (IQR 81-114) days. Most patients (96.8%, n = 1589) had surgery within 180 days of starting radiation, while 52 patients (3.2%) had delayed surgery. Black race and clinical T stage were associated with delayed surgery. Rates of pathologic upstaging, downstaging, complete response, and positive margins were not significantly different between the groups. Patients with delayed surgery had increased major morbidity as measured by a composite of length of hospital stay, readmission, and 30-day mortality [42.3% (22/52) vs 22.3% (355/1589), p = 0.001]. However, delayed surgery was not associated with a significant difference in survival in both univariate [5-year survival 32.8% (95% CI 21.1-50.7) vs 47.3% (44.7-50.1), p = 0.19] and multivariable analysis [hazard ratio (HR) 1.23 (0.85-1.78), p = 0.26].CONCLUSIONS: Delaying surgery longer than 180 days after starting chemoradiation for esophageal squamous cell carcinoma is associated with worse perioperative outcomes but not long-term survival.
View details for DOI 10.1245/s10434-022-12980-5
View details for PubMedID 36572807