1. Business in Medicine and its Effect on Resident Education Jennifer Litwin D.O. HO4, Randy Wobser M.D. Creighton University Medical Center Omaha, NE Introduction On September 1, 2014, in-network participation with Blue Cross and Blue Shield of Nebraska and the primary resident teachings hospitals, Alegent Creighton and Bergan Mercy Hospital, ended. The result was a loss of patients with this carrier from the resident case load. While these two big institutions work to resolve their differences, many - - including patients and residents, were caught in the middle. Traditionally, high volume and long hours during residency were considered necessary to ensure both competency and patient safety in training. With the shift in patient coverage at these training institutions concern has been raised on adequate volume to produce competent doctors. Surgical volume is important for evaluating resident experience, skill, and to ensure adequate clinical resources. Our study analyzes the effects and potential effects of financial driven business decisions on the quantity and quality of resident teaching at Creighton's two main resident training hospitals. Reviewing procedures/case logs for all residents to ensure adequate clinical resources. By analyzing the volume we are able to: –Make adjustments that may be needed to maintain resident education and experience –Ensure that the program has adequate numbers to meet procedure requirements Study Design: Retrospective observational study The Null hypothesis is that procedural volume pre and post-loss of insurance contract will be the same.. Methods Results Discussion References 1.[ACGME] Accreditation Council for Graduate Medical Education. ACGME common program requirements. http://www.acgme.org/acWebsite/ dutyHours dh_dutyhoursCommonPR07012007.pdf. Accessed June 6, 2013. 2.[ACGME] Accreditation Council for Graduate Medical Education. ACGME institutional requirements. http://www.acgme.org/acWebsite/irc/ irc_IRCpr07012007.pdf. Accessed June 6, 2013. 3.Simpson D, Lypson ML. The year is over, now what? the annual program evaluation. J Grad Med Educ. 2011;3(3):435–437. In addition, there was no detectable difference in the proportion of deliveries that were attended by residents between 2013 and 2014;The odds ratio (2013 to 2014) is 1.04, p-value = 0.6618; 95% confidence interval (0.96, 1.14). In light of the immediate decrease in both surgical and clinical volume, residents at Creighton were provided the opportunity to seek out surgery at additional affiliated facilities in the greater Omaha metro area. Starting in September residents began working more extensively with contributed faculty at all CHI facilities in the metro area as well as at the outpatient surgical centers. With these new opportunities resident case volume remained steady. Furthermore, this shows the personal motivation and drive the residents at Creighton have to maintain a robust surgical experience. One of the limitations of our study is that it is biased by resident reporting. Resident procedure numbers were collected from ACGME, a self reporting site. We attempted to eliminate that bias by looking at the proportion of cases where residents were primary surgeon vs the total number of cases. We were able to preform this with deliveries; however, due to the inability to tract total surgical opportunities across 9 locations we were unable to eliminate that bias for gynecological cases. Data on gynecological and obstetric volume was collected from the ACGME database as well as hospital scheduling from two major teaching hospitals for 2012, 2013, and 2014. To eliminate any seasonal variation the same quarters were compared with each other. Initial preliminary data indicated that surgical volume was affected (decreased). However, affiliations with contributing faculty allowed for experiences at outside facilities that added to resident cases. These additional numbers were also taken into account in our analysis. The chi-square goodness of fit test for your data indicates that there is a difference amongst the years (p = 0.0118). Rather than go through each of the independent 2x2 tables to determine where the difference lies, I calculated the 95% confidence interval for the proportion of each type of procedure. The line centered on each bar above represents the confidence interval. The area where there is a difference is in the proportion of other cases across years; specifically, the lower bound for 2014 does not overlap the upper bound for 2012. Initial results did show a difference of approximately 28% in overall gynecologic volume as shown below; however, when separated out into type of case there was not a statistical difference. Despite an estimated global decrease of approximately 30% for surgical and clinical volume interventions implemented during this time of transition made for a minimal impact on resident surgical experience. Another consideration to the surgical volume at Creighton is effect of robotic surgery. In an era where attendings are transitioning their preferred mode of hysterectomy and comfort with new technology it can leave resident out of the primary surgeon role when they may have been previously. Table 1: Minimum Resident Case Numbers Conclusions In regards to deliveries, with the p values being 0.6618 and thus not statistically significant we can accept the null hypothesis. In terms of gynecological volume, there was a significant difference with a P value of 0.0118. Further analysis needs to be done on route of surgical, specifically hysterectomy and vaginal vault suspensions and its influence on resident participation. At this time we can thus conclude that the interventions to improve resident surgical experience in the light of decreased volume at our primary hospitals has augmented the anticipated effect on resident education while maintaining and optimizing resident training. With that being said, it is important for training institutions to be cognizant of changes in the educational environment and be adaptable to insure that they produce competent doctors. Number of cases preformed by 3 rd year OB/GYN residents September to October Resident AttendedNo ResidentTotal 20137523851137 20147644081172 Total15167932309 Table 2: Delivery numbers for 2014 and 2015