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Eakes AM, Burkbauer L, Purcell LN, Akinkuotu AC, McLean SE, Charles AG, Phillips MR. Difference in Postoperative Outcomes and Perioperative Resource Utilization Between General Surgeons and Pediatric Surgeons: A Systematic Review. Am Surg 2023; 89:3739-3744. [PMID: 37150834 DOI: 10.1177/00031348231173943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/09/2023]
Abstract
Background: Both general surgeons (GS) and pediatric surgeons (PS) perform a high volume of appendectomies in pediatric patients, but there is a paucity of data on these outcomes based on surgeon training. We performed a systematic review and meta-analysis to compare postoperative outcomes and perioperative resource utilization for pediatric appendectomies.Methods: We searched PubMed to identify articles examining the association between surgeon specialization and outcomes for pediatric patients undergoing appendectomies. Study selection, data extraction, risk of bias assessment, and quality assessment were performed by one reviewer, with another reviewer to resolve discrepancies.Results: We identified 4799 articles, with 98.4% (4724/2799) concordance after initial review. Following resolution of discrepancies, 16 studies met inclusion criteria. Of the studies that reported each outcome, GS and PS demonstrated similar rates of readmission within 30 days (pooled RR 1.61 95% CI 0.66, 2.55) wound infections (pooled RR 1.07, 95% CI .55, 1.60), use of laparoscopic surgery (pooled RR 1.87, 95% CI .21, 3.53), postoperative complications (pooled RR 1.40, 95% CI .83, 1.97), use of preoperative imaging (pooled RR .98,95% CI .90, 1.05), and intra-abdominal abscesses (pooled RR .80, 95% CI .03, 1.58). Patients treated by GS did have a significantly higher risk of negative appendectomies (pooled RR 1.47, 95% CI 1.10, 1.84) when compared to PS.Discussion: This is the first meta-analysis to compare outcomes for pediatric appendectomies performed by GS compared to PS. Patient outcomes and resource utilization were similar among PS and GS, except for negative appendectomies were significantly more likely with GS.
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Affiliation(s)
- Ali M Eakes
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Laura Burkbauer
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Laura N Purcell
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Adesola C Akinkuotu
- Department of Surgery, Division of Pediatric Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Sean E McLean
- Department of Surgery, Division of Pediatric Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Anthony G Charles
- Department of Surgery, Division of General and Acute Care Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Michael R Phillips
- Department of Surgery, Division of Pediatric Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Georgeades C, Farazi MR, Gainer H, Flynn-O'Brien KT, Leys CM, Gourlay D, Van Arendonk KJ. Distribution of acute appendicitis care in children: A statewide assessment of the surgeons and facilities providing surgical care. Surgery 2023; 173:765-773. [PMID: 36244816 DOI: 10.1016/j.surg.2022.06.053] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 06/06/2022] [Accepted: 06/21/2022] [Indexed: 01/01/2023]
Abstract
BACKGROUND Pediatric appendicitis is managed by general and pediatric surgeons at both children's hospitals and non-children's hospitals. A statewide assessment of surgeons and facilities providing appendicitis care was performed to identify factors associated with location of surgical care. METHODS Children aged <18 years undergoing appendectomy for appendicitis in Wisconsin from 2018-2020 were identified through the International Classification of Diseases, 10th revision, and Current Procedural Terminology codes using Wisconsin Hospital Association data. Patient residence and hospital locations were used to determine travel distance, rurality, and neighborhood-level socioeconomic status. RESULTS Among 3,604 children with appendicitis, 36.0% and 12.8% had an appendectomy at 2 major children's hospitals and 4 other children's hospitals, respectively, and 51.2% had an appendectomy at 99 non-children's hospitals. Pediatric surgeons performed 76.1% of appendectomies at children's hospitals and 2.9% at non-children's hospitals. Only 32.2% of patients received care at the hospital closest to their homes. Non-children's hospitals disproportionally cared for older, non-Hispanic White, and privately insured children, those with uncomplicated appendicitis, and those living in rural areas, in mid-socioeconomic status neighborhoods, and greater distances from children's hospitals (all P < .001). After multivariable adjustment, receipt of care at children's hospitals was associated with younger age, minority race, complicated appendicitis, shorter distance to children's hospitals, and urban residence. CONCLUSION Over half of surgical care for pediatric appendicitis occurred at non-children's hospitals, especially among older children and those living in rural areas far from children's hospitals. Future work is necessary to determine which children benefit most from care at children's hospitals and which can safely receive care at non-children's hospitals to avoid unnecessary time and resource utilization associated with travel to children's hospitals.
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Affiliation(s)
- Christina Georgeades
- Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI.
| | - Manzur R Farazi
- Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Hailey Gainer
- Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | | | - Charles M Leys
- Division of Pediatric Surgery, Department of Surgery, University of Wisconsin, Madison, WI
| | - David Gourlay
- Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Kyle J Van Arendonk
- Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
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Purcell LN, Eakes A, Ricketts T, McLean SE, Akinkuotu A, Hayes AA, Charles AG, Phillips MR. Appendectomy by Pediatric Surgeons in North Carolina is Associated With Higher Charge Than General Surgeons. J Surg Res 2023; 281:299-306. [PMID: 36228340 DOI: 10.1016/j.jss.2022.08.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 08/03/2022] [Accepted: 08/20/2022] [Indexed: 11/07/2022]
Abstract
INTRODUCTION The delivery of pediatric surgical care for acute appendicitis involves general surgeons (GS) and pediatric surgeons (PS), but the differences in clinical practice are primarily undescribed. We examined charge differences between GS and PS for the treatment of pediatric acute appendicitis. METHODS We performed a retrospective review of the North Carolina hospital discharge database (2013-2017) in pediatric patients (≤18 y) who had surgery for appendiceal pathology (acute or chronic appendicitis and other appendiceal pathology). We performed a bivariate analysis of surgical charges over the type of surgical providers (GS, PS, other specialty, and unassigned surgeons). RESULTS Over the study period, 21,049 patients had appendicitis or other diseases of the appendix, and 15,230 (72.4%) underwent appendectomy. Patients who were operated on by PS were younger (10 y, interquartile range (IQR): 6-13 versus 13 y, IQR: 9-16, P < 0.001). Acute appendicitis was diagnosed in 2860 (44.3%) and 3173 (49.2%) of the PS and GS cohorts, respectively, P = 0.008. PS compared to GS performed a higher percentage of laparoscopic (n = 2,697, 89.4% versus n = 2,178, 65.5%) than open appendectomies (n = 280, 9.3% versus n = 1,118, 33.6%), P < 0.001. The overall hospital charges were $28,081 (IQR: $21,706-$37,431) and $24,322 (IQR: $17,906-$32,226) for PS and GS, respectively, P < 0.001. Surgical charges where higher for PS than GS, $12,566 (IQR: $9802-$17,462) and $8051 (IQR: $5872-$2331), respectively. When controlling for diagnosis, surgical approach, emergent status, age, and surgical cost of appendiceal surgery, and hospital charges following appendiceal surgery were $4280 higher for PS than GS (95% CI: 3874-4687). CONCLUSIONS The total charge for operations for appendiceal disease is significantly higher for PS compared to GS. Pediatric surgeons had increased surgical charges compared to GS but decreased radiology charges. The specific reasons for these differences are not clearly delineated in this data set and persist after controlling for relevant covariates. However, these data demonstrate that increasing value in pediatric appendicitis may require specialty-based targets.
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Affiliation(s)
- Laura N Purcell
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Ali Eakes
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Thomas Ricketts
- The Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Sean E McLean
- Division of Pediatric Surgery, Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Adesola Akinkuotu
- Division of Pediatric Surgery, Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Andrea A Hayes
- Division of Pediatric Surgery, Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Anthony G Charles
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Division of Trauma and Acute Care Surgery, Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Michael R Phillips
- Division of Pediatric Surgery, Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
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Lo HYA, Yang C, Rettig RL, Chung J, Shaul D, Sydorak R. Same day discharge after pediatric laparoscopic appendectomy in community hospitals. J Pediatr Surg 2022; 57:1242-1248. [PMID: 35379493 DOI: 10.1016/j.jpedsurg.2022.02.038] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 02/23/2022] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Same-day discharge (SDD) protocols after pediatric laparoscopic appendectomy have not been well studied in a community hospital setting, especially when hospitals with low inpatient pediatric censuses are increasingly closing their pediatric units. This study evaluates the outcomes of a SDD protocol after pediatric appendectomy that was implemented across an integrated healthcare system in which hospitals experienced closure of pediatric units. METHODS Patients between ages 6 to 13 years-old who underwent laparoscopic appendectomy for uncomplicated appendicitis from January 1st 2015 to December 31st 2020 were reviewed. During the study period, an inter-hospital SDD protocol was introduced at nine hospitals, four of which closed their pediatric units. RESULTS There were 1293 patients in the pre-protocol cohort and 953 patients in the post-protocol cohort. There were 588 (45.5%) patients who underwent SDD in the pre-protocol cohort, compared with 804 (84.4%) patients in the post-protocol cohort (p<0.00001). Postoperative narcotics were prescribed to 358 (27.7%) patients in the pre-protocol cohort, compared to 482 (50.6%) patients in the post-protocol cohort (P<0.00001). There was no difference in the 30-day emergency department visit rate or 30-day readmission rate between the two cohorts. A subgroup analysis comparing the surgical outcomes at community hospitals with and without pediatric units after implementation of the SDD protocol showed no difference. CONCLUSION Same-day discharge after laparoscopic appendectomy for uncomplicated appendicitis in community hospitals, even after pediatric unit closure, is safe and feasible. The decrease in postoperative LOS and the increase in SDD are not associated with higher complication rates.
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Affiliation(s)
- Hoi Yee Annie Lo
- General Surgery Department, Kaiser Permanente Los Angeles Medical Center, 4760 Sunset Blvd, 3rd Floor, Los Angeles, CA 90027, United States
| | - Claire Yang
- General Surgery Department, Kaiser Permanente Los Angeles Medical Center, 4760 Sunset Blvd, 3rd Floor, Los Angeles, CA 90027, United States
| | - Robert Luke Rettig
- General Surgery Department, Kaiser Permanente Los Angeles Medical Center, 4760 Sunset Blvd, 3rd Floor, Los Angeles, CA 90027, United States
| | - Joanie Chung
- Kaiser Permanente Research and Evaluation, 100 S Los Robles Ave #2, Pasadena, CA 91101, United States
| | - Donald Shaul
- Children's Hospital of Orange County, CHOC Children's Commerce Tower, 505 S Main St UNIT 225, Orange, CA 92868, United States
| | - Roman Sydorak
- General Surgery Department, Kaiser Permanente Los Angeles Medical Center, 4760 Sunset Blvd, 3rd Floor, Los Angeles, CA 90027, United States.
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Sogbodjor LA, Singleton G, Davenport M, Walker S, Moonesinghe SR. Quality metrics for emergency abdominal surgery in children: a systematic review. Br J Anaesth 2021; 128:522-534. [PMID: 34895715 DOI: 10.1016/j.bja.2021.10.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 10/07/2021] [Accepted: 10/13/2021] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND There is variation in care quality and outcomes for children undergoing emergency abdominal surgery, such as appedectomy. Addressing this requires paediatric-specific quality metrics. The aim of this study was to identify perioperative structure and process measures that are associated with improved outcomes for these children. METHODS We performed a systematic review searching MEDLINE, Embase, CINAHL, Cochrane Library, and Google Scholar for articles published between January 1, 1980 and September 29, 2020 about the perioperative care of children undergoing emergency abdominal surgery. We also conducted secondary searching of references and citations, and we included international professional publications. RESULTS We identified and analysed 383 peer-reviewed articles and 18 grey literature publications. High-grade evidence pertaining to the perioperative care of this patient group is limited. Most of the evidence available relates to improving diagnostic accuracy using preoperative blood testing, imaging, and clinical decision tools. Processes associated with clinical outcomes include time lapse between time of presentation or initial assessment and surgery, and the use of particular analgesia and antibiotic protocols. Structural factors identified include hospital and surgeon caseload and the use of perioperative care pathways. CONCLUSIONS This review summarises the structural and process measures associated with outcome in paediatric emergency abdominal surgery. Such measures provide a means of evaluating care and identifying areas of practice that require quality improvement, especially in children with appendicitis. CLINICAL TRIAL REGISTRATION PROSPERO CRD42017055285.
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Affiliation(s)
- Lisa A Sogbodjor
- Centre for Perioperative Medicine, Research Department for Targeted Intervention, UCL Division of Surgery and Interventional Science, London, UK; UCLH Surgical Outcomes Research Centre, Department of Anaesthesia and Perioperative Medicine, University College London Hospitals NHS Foundation Trust, London, UK; Health Services Research Centre, National Institute for Academic Anaesthesia, Royal College of Anaesthetists, London, UK; Department of Anaesthesia and Pain Medicine, Great Ormond Street Hospital NHS Foundation Trust, London, UK.
| | - Georgina Singleton
- Centre for Perioperative Medicine, Research Department for Targeted Intervention, UCL Division of Surgery and Interventional Science, London, UK; UCLH Surgical Outcomes Research Centre, Department of Anaesthesia and Perioperative Medicine, University College London Hospitals NHS Foundation Trust, London, UK; Health Services Research Centre, National Institute for Academic Anaesthesia, Royal College of Anaesthetists, London, UK
| | - Mark Davenport
- Department of Paediatric Surgery, King's College Hospital, London, UK
| | - Suellen Walker
- Department of Anaesthesia and Pain Medicine, Great Ormond Street Hospital NHS Foundation Trust, London, UK; Clinical Neurosciences, UCL Great Ormond St Institute of Child Health, London, UK
| | - S Ramani Moonesinghe
- Centre for Perioperative Medicine, Research Department for Targeted Intervention, UCL Division of Surgery and Interventional Science, London, UK; UCLH Surgical Outcomes Research Centre, Department of Anaesthesia and Perioperative Medicine, University College London Hospitals NHS Foundation Trust, London, UK; Health Services Research Centre, National Institute for Academic Anaesthesia, Royal College of Anaesthetists, London, UK
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Cummins CB, Bowen-Jallow KA, Tran S, Radhakrishnan RS. Education of pediatric surgery residents over time: Examining 15 years of case logs. J Pediatr Surg 2021; 56:85-98. [PMID: 33139026 PMCID: PMC9618151 DOI: 10.1016/j.jpedsurg.2020.09.038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 09/22/2020] [Indexed: 01/30/2023]
Abstract
BACKGROUND/PURPOSE Surgical indications and techniques have changed over the last 15 years. The number of Pediatric Surgery training programs has also increased. We sought to examine the effect of these changes on resident education by examining case log data. METHODS Accreditation Council for Graduate Medical Education (ACGME) case logs for graduating Pediatric Surgery residents were examined from 2004 to 2018. Using the summary statistics provided, linear regression analysis was conducted on each case log code and category. RESULTS In 2004, there were 24 Pediatric Surgery training programs and 24 Pediatric Surgery residents graduating with an average of 979.8 total cases logged. In 2018, there were 36 programs with 38 residents graduating with an average of 1260.2 total cases logged. Total case volume of graduating residents significantly increased over the last 15 years (p < 0.001). Significant increases were demonstrated in skin/soft tissue/musculoskeletal (p < 0.01), abdominal (p < 0.001), hernia repair (p < 0.001), genitourinary (p < 0.01), and endoscopy (p < 0.001). No significant changes were seen in the head and neck, thoracic, cardiovascular, liver/biliary, and non-operative trauma categories. No categories significantly decreased over the time period. No significant changes were seen in the number of multiple index congenital cases, including tracheoesophageal fistula/esophageal atresia repair, omphalocele, gastroschisis, choledochal cyst excision, perineal procedure for imperforate anus, and major hepatic resections for tumors. Pertinent increases in specific procedures include diaphragmatic hernia repair (p < 0.01), ECMO cannulation/decannulation(p < 0.05), thyroidectomy (p < 0.001), parathyroidectomy (p < 0.001), biliary atresia (p < 0.001), and circumcision (p < 0.001) as well as most laparoscopic abdominal procedures. Specific procedure codes with significant decreases include tracheostomy (p < 0.05), minimally invasive decortication/pleurectomy/blebectomy (p < 0.001), laparoscopic splenectomy (p < 0.001), as well as most open abdominal procedures. CONCLUSION Despite increasing numbers of Pediatric Surgery residents and training programs, the number of cases performed by each graduating resident has increased. This increase is primarily fueled by increase in abdominal, skin/soft tissue/musculoskeletal, hernia repair, genitourinary, and endoscopic cases. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Claire B. Cummins
- Department of Surgery, University of Texas Medical Branch, 301 University Blvd., Galveston, TX 75555-0353, USA
| | - Kanika A. Bowen-Jallow
- Division of Pediatric Surgery, University of Texas Medical Branch, 301 University Blvd., Galveston, TX 75555-0353, USA
| | - Sifrance Tran
- Division of Pediatric Surgery, University of Texas Medical Branch, 301 University Blvd., Galveston, TX 75555-0353, USA
| | - Ravi S. Radhakrishnan
- Division of Pediatric Surgery, University of Texas Medical Branch, 301 University Blvd., Galveston, TX 75555-0353, USA
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Rolle U, Fahlenbach C, Heidecke CD, Heller G, Meyer HJ, Schuler E, Waibel B, Jeschke E, Günster C, Maneck M. Rates of Complications After Appendectomy in Children and Adolescents: Pediatric Surgical Compared to General Surgical Hospitals. J Surg Res 2020; 260:467-474. [PMID: 33272597 DOI: 10.1016/j.jss.2020.11.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 10/08/2020] [Accepted: 11/01/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Appendectomies in children and adolescents are performed in Germany in pediatric surgical (PS) or general surgical hospitals (GS). The aim of this study is to evaluate whether the surgery in a PS or GS hospital has an influence on the postoperative course after appendectomy in children and adolescents. MATERIALS AND METHODS Nationwide routine data from children and adolescents aged 1-17 y insured by the Local Health Insurance Fund who underwent appendectomy between 2014 and 2016 were analyzed (cohort study). Descriptive statistics were calculated both overall and in the two groups (PS and GS). Patients were additionally examined by age (1-5, 6-12, and 13-17 y), treatment (laparoscopic, open surgical, and conversion), and appendicitis type (nonacute: K36/K37/K38/R10, acute simple: K35.30/K35.8, and acute complex: K35.2/K35.31/K35.32). The influence of surgeon specialization on 90-d secondary surgery and 90-d general complications was assessed by multiple logistic regression. RESULTS Altogether, 25,065 patients who underwent surgery in 83 PS and 906 GS hospitals were included. Logistic regression analysis revealed that PS was associated with a reduced risk of interventions in the 1-5- and 6-12-y age groups (odds ratio: 0.44, 0.62). Acute complex appendicitis, comorbidities, and open surgery significantly increased the risk for reintervention. PS was associated with an increased risk for complications in the 13-17-y age group (odds ratio: 1.66). CONCLUSIONS PS and GS hospitals provided safe appendectomies in children and adolescents with low reintervention and complication rates. PS hospitals demonstrated advantages for patients in the 1-5- and 6-12-y age groups and GS hospitals for patients 13-17 y.
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Affiliation(s)
- Udo Rolle
- Department of Paediatric Surgery and Paediatric Urology, University Hospital, Goethe University, Frankfurt/Main, Germany.
| | | | - Claus-Dieter Heidecke
- Department of General, Visceral, Thoracic and Vascular Surgery, University Medicine Greifswald, Greifswald, Germany
| | - Günther Heller
- Department of Medicine, University Marburg, Marburg, Germany
| | | | - Ekkehard Schuler
- Department of Quality Management, Helios Hospital, Berlin, Germany
| | - Beate Waibel
- Medical Review Board of the Social Health Insurance Funds, Freiburg, Germany
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Knotts CM, Prange EJ, Orminski K, Thompson S, Richmond BK. The Provision of Acute Pediatric Surgical Care by Adult Acute Care General Surgeons : Is There a Learning Curve? Am Surg 2020; 86:1640-1646. [PMID: 32683921 DOI: 10.1177/0003134820933251] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND At our hospital, acute surgical care of children aged 6 and older is managed by adult acute care surgeons. Previously published data from a 10-year experience with this model demonstrated no differences in outcomes when compared with pediatric surgical benchmark data. This study assesses for the effects of a learning curve in the care of pediatric patients by comparing outcomes of patients treated in the first three years with those treated in the last 3 years during a 10-year experience with this model. DESIGN This was a retrospective study of pediatric patients aged 6 and older who underwent an emergent or urgent, nontrauma surgical procedure by a general surgeon. Data was obtained via chart review and descriptive statistics were compared between patients operated on between January 1, 2009-January 1, 2012 and January 1, 2016-January 1, 2019. RESULTS In all, 208 cases were performed in the early cohort and 192 cases in the late cohort. Appendectomy was the most common procedure in both intervals (88% early, 94.8% late). Although there was a significant decrease in open procedures in the later cohort (22.6% vs 4.7%, P < .001), there was no significant change in disease-specific complications or negative appendectomies. No consults to a fellowship-trained pediatric surgeon were required during either time period, although one was available if needed. CONCLUSIONS Our data demonstrated a decrease in the number of open procedures in the later cohort. This may be due to an increased comfort level with pediatric laparoscopy over time. However, no significant changes in outcomes were observed. This study supports that acute care general surgeons can provide comparable care to pediatric patients within this age demographic and that although a learning curve, appears to exist with respect to pediatric laparoscopy, it is insignificant in terms of its effect on overall outcomes.
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Affiliation(s)
- Chelsea M Knotts
- 12355Department of Surgery, West Virginia University/Charleston Division, Charleston, WV, USA
| | - Edward J Prange
- 12355West Virginia University School of Medicine/Charleston Division, Charleston, WV, USA
| | - Krysta Orminski
- 12355West Virginia University School of Medicine/Charleston Division, Charleston, WV, USA
| | - Stephanie Thompson
- 20205Charleston Area Medical Center Health Education and Research Institute, Charleston, WV, USA
| | - Bryan K Richmond
- 12355Department of Surgery, West Virginia University/Charleston Division, Charleston, WV, USA
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O'Connell RM, Elwahab SA, Mealy K. Should all paediatric appendicectomies be performed in a specialist or high-volume setting? Ir J Med Sci 2020; 189:1015-1021. [PMID: 31898162 DOI: 10.1007/s11845-019-02156-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Accepted: 11/26/2019] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Acute appendicitis is a common surgical emergency in children. The majority of appendicectomies in children are performed by general surgeons, rather than specialist paediatric surgeons. AIM To assess the impact of hospital specialization, hospital volume, and surgeon volume on outcomes for children undergoing appendicectomy in Ireland. METHODS NQAIS (National Quality Assurance and Improvement System) data for all appendicectomies performed on children in Ireland between January 2014 and November 2017 was examined. Hospitals were categorized as specialist paediatric centres (SPCs), high-volume general (HVGHs), moderate-volume general (MVGHs), or low-volume general (LVGHs) by annual case volume. Similarly, surgeons were categorized as high-volume (HVSs), moderate-volume (MVSs), or low-volume (LVSs) by annual volume. Data relating to patient demographics, type of surgery (open/laparoscopic/laparoscopic converted to open), length of stay (LOS), mortality, admission to critical care, and readmission rates were collected and analysed. RESULTS About 9593 appendicectomies were performed in 21 hospitals by 134 surgeons. Patients in SPCs had lowest overall rates of laparoscopic surgery (48% v 66% (HVGHs) v 70% (MVGHs) v 57%(LVGHs), p < 0.001). In SPCs 30-day readmission rates were lower for younger children (5.3% for 5-8-year olds v 6.7% (HVGHs) v 7.3%(MVGHs) v 10.5% (LVGHs), p = 0.023). HVSs performed more laparoscopic appendicectomies on younger patients (0-4 years: 40% v 6% (MVSs) v 17%(LVSs), p < 0.001) but performed the least on older children (13-16 years: 76% v 82%(MVSs) v 82%(LVSs), p < 0.001). CONCLUSION Children younger than 8 years undergoing appendicectomy in HVGHs or SPCs, or by HVSs, have marginally better outcomes. In older children, marginally shorter in-hospital stays and higher laparoscopic rates are seen in those looked after outside of high-volume or specialist units. Our results show that nonspecialist centres provide an essential, and safe, service to paediatric patients with acute appendicitis.
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Affiliation(s)
| | - Sami Abd Elwahab
- Department of Surgery, Wexford General Hospital, Wexford, Ireland
| | - Kenneth Mealy
- Department of Surgery, Wexford General Hospital, Wexford, Ireland
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10
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Almström M, Svensson JF, Svenningsson A, Hagel E, Wester T. Population-based cohort study of the correlation between provision of care and the risk for complications after appendectomy in children. J Pediatr Surg 2019; 54:2279-2284. [PMID: 30992147 DOI: 10.1016/j.jpedsurg.2019.03.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2018] [Revised: 03/19/2019] [Accepted: 03/20/2019] [Indexed: 11/15/2022]
Abstract
PURPOSE To investigate the impact of hospital administrative level and caseload of pediatric appendectomies on the morbidity and mortality after appendectomy in a population-based cohort of Swedish children. METHODS Population-based cohort study including all Swedish children less than 15 years of age that underwent appendectomy for suspected appendicitis, 1987-2009. Patient characteristics and data on postoperative morbidity and mortality were collected from the Swedish National Patient Register and the Swedish Death Register. Primary endpoints were postoperative morbidity and mortality. Two explanatory variables were investigated: hospital administrative level and hospital annual caseload of pediatric appendectomies. Data were analyzed in regression models adjusting for available confounders. RESULTS The cohort comprised 55,591 children. The risk for postoperative complications was reduced in specialized pediatric surgical centers and in high caseload centers, compared to other hospitals. There were only seven postoperative deaths within 90 days of appendectomy. CONCLUSIONS We found clinically relevant risk reductions for reoperation and for readmission after appendectomy in specialized pediatric surgical centers. Importantly, the risk for postoperative complications was also reduced with increased hospital caseload, indicating that the merit from centralizing the management of pediatric appendectomies to specialized pediatric surgical centers may also be achieved by increasing hospital caseload of pediatric appendectomies in non-pediatric surgical units. TYPE OF STUDY Treatment study. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Markus Almström
- Department of Pediatric Surgery, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden; Departments of Women's and Children's Health, Stockholm, Sweden.
| | - Jan F Svensson
- Department of Pediatric Surgery, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden; Departments of Women's and Children's Health, Stockholm, Sweden
| | - Anna Svenningsson
- Department of Pediatric Surgery, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden; Departments of Women's and Children's Health, Stockholm, Sweden
| | - Eva Hagel
- Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden
| | - Tomas Wester
- Department of Pediatric Surgery, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden; Departments of Women's and Children's Health, Stockholm, Sweden
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11
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Akhtar-Danesh GG, Doumouras AG, Flageole H, Hong D. Geographic and socioeconomic predictors of perforated appendicitis: A national Canadian cohort study. J Pediatr Surg 2019; 54:1804-1808. [PMID: 30482382 DOI: 10.1016/j.jpedsurg.2018.10.065] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2018] [Revised: 10/10/2018] [Accepted: 10/16/2018] [Indexed: 12/28/2022]
Abstract
BACKGROUND/PURPOSE Appendiceal perforation significantly impacts the outcomes of pediatric appendicitis. While socioeconomic status affects perforation risk in the United States, these effects should dissipate in a universal healthcare system. The specific spatial patterns associated with perforation have also never been delineated. This study examined the effect of geography and SES on appendiceal perforation in Canada's universal healthcare system. METHODS Using administrative databases, Canadian children with appendicitis from 2008 to 2015 were identified. Perforation rates were examined based on rurality, distance from treating hospital, and SES. A spatial analysis identified neighborhoods with high perforation rates. Predictors of high perforation clusters were determined using logistic regression. RESULTS Over the study period, 43,055 children with appendicitis were identified. The overall perforation rate was 31.5%. Rural neighborhoods and those >125 km from the treating hospital were more likely to be within a high perforation cluster (OR 2.39, 95%CI 1.31-4. 02, p = 0.001; and OR 2.55, 95%CI 1.35-4.47, p = 0.001, respectively). Children in high perforation clusters were more likely to suffer complications. SES was not associated with perforation rates. CONCLUSIONS In this population-based study, appendiceal perforation was not a function of SES, but a spatial phenomenon. These findings highlight disparities in access to surgical care in Canada. LEVEL OF EVIDENCE Prognosis study, level II.
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Affiliation(s)
- Gileh-Gol Akhtar-Danesh
- Department of Surgery, McMaster University, 1280 Main Street West, Hamilton, Ontario, L8S 4L8, Canada.
| | - Aristithes G Doumouras
- Department of Surgery, McMaster University, 1280 Main Street West, Hamilton, Ontario, L8S 4L8, Canada; Division of General Surgery, St. Joseph's Healthcare, 50 Charlton Avenue East, Hamilton, Ontario, L8N 4A6, Canada.
| | - Helene Flageole
- Department of Surgery, McMaster University, 1280 Main Street West, Hamilton, Ontario, L8S 4L8, Canada; Division of Pediatric Surgery, McMaster University, 1280 Main Street West, Hamilton, Ontario, L8S 4L8, Canada.
| | - Dennis Hong
- Department of Surgery, McMaster University, 1280 Main Street West, Hamilton, Ontario, L8S 4L8, Canada; Division of General Surgery, St. Joseph's Healthcare, 50 Charlton Avenue East, Hamilton, Ontario, L8N 4A6, Canada.
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Flynn-O’Brien KT, Richards MK, Wright DR, Rivara FP, Haaland W, Thompson L, Oldham K, Goldin A. Health outcomes and the healthcare and societal cost of optimizing pediatric surgical care in the United States. J Pediatr Surg 2019; 54:621-627. [PMID: 30598246 PMCID: PMC6511280 DOI: 10.1016/j.jpedsurg.2018.10.102] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Revised: 10/21/2018] [Accepted: 10/26/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND There is a movement to ensure that pediatric patients are treated in appropriately resourced hospitals through the ACS Children's Surgery Verification (CSV) program. The objective of this study was to assess the potential difference in care provision, health outcomes and healthcare and societal costs after implementation of the CSV program. METHODS All 2011 inpatient admissions for selected complex pediatric patients warranting treatment at a hospital with Level I resources were evaluated across 6 states. Multivariate regressions were used to analyze differences in healthcare outcomes (postoperative complications including death, length of stay, readmissions and ED visits within 30 days) and costs by CSV level. Recycled predictions were used to estimate differences between the base case scenario, where children actually received care, and the optimized scenario, where all children were theoretically treated at Level I centers. RESULTS 8,006 children (mean age 3.06 years, SD 4.49) met inclusion criteria, with 45% treated at Level I hospitals, 30% at Level II and 25% at Level III. No statistically significant differences were observed in healthcare outcomes. Readmissions within 30 days were higher at Level II compared to Level I centers (adjusted IRR 1.61; 95% CI 1.11, 2.34), with an estimated 24 avoidable readmissions per 1000 children if treatment were shifted from Level II to Level I centers. Overall, costs per child were not significantly different between the base case and the optimized scenario. CONCLUSION Many complex surgical procedures are being performed at Level II/III centers. This study found no statistically significant increase in healthcare or societal costs if these were performed instead at Level I centers under the optimized scenario. Ongoing evaluation of efforts to match institutional resources with individual patient needs is needed to optimize children's surgical care in the United States. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Katherine T. Flynn-O’Brien
- Department of Surgery, Children’s Hospital of Wisconsin, Division of Pediatric Surgery, Fellow, Pediatric Surgery, 999 North 92nd Street, C320, Milwaukee, WI 53226, 505.948.0220,
| | - Morgan K. Richards
- Department of Surgery, Children’s Healthcare of Atlanta, Division of Pediatric Surgery, Fellow, Pediatric Surgery, 1405 Clifton Rd NE, Atlanta, GA 30322, 206.369.8387,
| | - Davene R. Wright
- Department of Pediatrics, University of Washington and Seattle Children’s Research Institute, Center for Child Health, Behavior, and Development, Assistant Professor, Division of General Pediatrics, 2001 Eighth Ave, Suite 400, Seattle, WA 98121 USA, 206-884-8241,
| | - Frederick P. Rivara
- Department of Pediatrics, University of Washington, Seattle Children’s Research Institute, Center for Child Health, Behavior and Development, Professor, Division of General Pediatrics, Harborview Injury Prevention and Research Center, Box 359960, 325 Ninth Ave, Seattle, WA 98104 USA, 206-744-9449,
| | - Wren Haaland
- Seattle Children's Research Institute, Center for Child Health, Behavior, and Development, 2001 Eighth Ave, Suite 400, Seattle, WA 98121, USA.
| | - Leah Thompson
- Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA.
| | - Keith Oldham
- Children's Hospital of Wisconsin, Medical College of Wisconsin, 999 North 92(nd) Street, C320, Milwaukee, WI 53226.
| | - Adam Goldin
- Department of Surgery, Seattle Children's Hospital, Division of Pediatric General and Thoracic Surgery, Seattle Children's Hospital, Department of Surgery, University of Washington School of Medicine, 4800 Sand Point Way NE, Seattle, WA 98105, USA.
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Pediatric appendicitis: Is referral to a regional pediatric center necessary? J Trauma Acute Care Surg 2019; 84:636-641. [PMID: 29283967 DOI: 10.1097/ta.0000000000001787] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Acute appendicitis is the most common emergent surgical procedure performed among children in the United States, with an incidence exceeding 80,000 cases per year. Appendectomies are often performed by both pediatric surgeons and adult general/trauma and acute care (TACS) surgeons. We hypothesized that children undergoing appendectomy for acute appendicitis have equivalent outcomes whether a pediatric surgeon or a TACS surgeon performs the operation. METHODS A retrospective chart review was performed for patients 6 to 18 years of age, who underwent appendectomy at either a regional children's hospital (Children's Hospital of Colorado [CHCO], n = 241) or an urban safety-net hospital (n = 347) between July 2010 and June 2015. The population of patients operated on at the urban safety-net hospital was further subdivided into those operated on by pediatric surgeons (Denver Health Medical Center [DHMC] pediatric surgeons, n = 68) and those operated on by adult TACS surgeons (DHMC TACS, n = 279). Baseline characteristics and operative outcomes were compared between these patient populations utilizing one-way analysis of variance and χ test for independence. RESULTS When comparing the CHCO and DHMC TACS groups, there were no differences in the proportion of patients with perforated appendicitis, operative time, rate of operative complications, rate of postoperative infectious complications, or rate of 30-day readmission. Length of stay was significantly shorter for the DHMC TACS group than that for the CHCO group. CONCLUSIONS Our data demonstrate that among children older than 5 years undergoing appendectomy, length of stay, risk of infectious complications, and risk of readmission do not differ regardless of whether they are operated on by pediatric surgeons or adult TACS surgeons, suggesting resources currently consumed by transferring children to hospitals with access to pediatric surgeons could be allocated elsewhere. LEVEL OF EVIDENCE Therapeutic/Care management, level III.
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Trauma surgeon performance of appendectomy in 5-year- to 10-year-old children is safe and decreases length of hospital stay. J Trauma Acute Care Surg 2018; 85:118-121. [PMID: 29554038 DOI: 10.1097/ta.0000000000001902] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Kvasnovsky CL, Lumpkins K, Diaz JJ, Chun JY. Emergency pediatric surgery: Comparing the economic burden in specialized versus nonspecialized children's centers. J Pediatr Surg 2018. [PMID: 29525274 DOI: 10.1016/j.jpedsurg.2018.02.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND The American College of Surgeons has developed a verification program for children's surgery centers. Highly specialized hospitals may be verified as Level I, while those with fewer dedicated resources as Level II or Level III, respectively. We hypothesized that more specialized children's centers would utilize more resources. STUDY DESIGN We performed a retrospective study of the Maryland Health Services Cost Review Commission (HSCRC) database from 2009 to 2013. We assessed total charge, length of stay (LOS), and charge per day for all inpatients with an emergency pediatric surgery diagnosis, controlling for severity of illness (SOI). Using published resources, we assigned theoretical level designations to each hospital. RESULTS Two hospitals would qualify as Level 1 hospitals, with 4593 total emergency pediatric surgery admissions (38.5%) over the five-year study period. Charges were significantly higher for children treated at Level I hospitals (all P<0.0001). Across all SOI, children at Level I hospitals had significantly longer LOS (all P<0.0001). CONCLUSION Hospitals defined as Level II and Level III provided the majority of care and were able to do so with shorter hospitalizations and lower charges, regardless of SOI. As care shifts towards specialized centers, this charge differential may have significant impact on future health care costs. LEVEL OF EVIDENCE Level III Cost Effectiveness Study.
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Affiliation(s)
- Charlotte L Kvasnovsky
- Department of Surgery, University of Maryland Medical Center, Baltimore, MD, United States.
| | - Kimberly Lumpkins
- Department of Surgery, University of Maryland Medical Center, Baltimore, MD, United States
| | - Jose J Diaz
- Division of Acute Care Surgery, Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD, United States
| | - Jeannie Y Chun
- Department of Pediatric Surgery, Providence Children's Health, Portland, OR, United States
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Litz CN, Ciesla DJ, Danielson PD, Chandler NM. Effect of hospital type on the treatment of acute appendicitis in teenagers. J Pediatr Surg 2018; 53:446-448. [PMID: 28408075 DOI: 10.1016/j.jpedsurg.2017.03.062] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Accepted: 03/30/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Teenagers receive appendicitis care at both adult and pediatric facilities. The purpose of this study was to evaluate outcomes following treatment of acute appendicitis in teenagers based on the type of hospital facility. METHODS Patients aged 13-17years with acute appendicitis who were discharged from acute care hospitals from 2009 to 2014 were identified using a statewide discharge dataset. Hospitals were classified as pediatric or adult and outcomes were compared. RESULTS There were 5585 patients treated in adult hospitals and 1625 in pediatric hospitals. Fewer patients at adult hospitals had complicated appendicitis (20.4% vs. 33.0%, p<0.01). Open appendectomy occurred more often in adult hospitals compared to pediatric hospitals (12.6% vs. 6.0%, p<0.01). Pediatric hospitals had higher rates of non-operative management (10% vs. 3.4%, p<0.01) and percutaneous drain placement (1.2% vs. 0.4%, p<0.01). Postoperative complication rates did not significantly differ between hospital types. CONCLUSION Most teenagers undergo appendectomy at adult facilities; however, a greater proportion of younger patients and patients with complicated appendicitis is treated at pediatric hospitals. Treatment at a freestanding children's hospital results in lower rates of open procedures and no difference in complications. Opportunities may exist to standardize care across treating facilities to optimize outcomes and resource use. TYPE OF STUDY Prognosis study. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Cristen N Litz
- Johns Hopkins All, Children's Hospital, Outpatient Care Center, 601 5(th) Street South, Dept 70-6600, 3(rd) Floor, Saint Petersburg, FL 33701.
| | - David J Ciesla
- University of South Florida, Morsani College of Medicine, 1 Tampa General Circle, G417, Tampa, FL 33606.
| | - Paul D Danielson
- Johns Hopkins All, Children's Hospital, Outpatient Care Center, 601 5(th) Street South, Dept 70-6600, 3(rd) Floor, Saint Petersburg, FL 33701.
| | - Nicole M Chandler
- Johns Hopkins All, Children's Hospital, Outpatient Care Center, 601 5(th) Street South, Dept 70-6600, 3(rd) Floor, Saint Petersburg, FL 33701.
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17
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Pediatric surgical capacity in Africa: Current status and future needs. J Pediatr Surg 2017; 52:843-848. [PMID: 28168989 DOI: 10.1016/j.jpedsurg.2017.01.033] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Accepted: 01/23/2017] [Indexed: 11/24/2022]
Abstract
BACKGROUND African pediatric surgery (PS) faces multiple challenges. Information regarding existing resources is limited. We surveyed African pediatric surgeons to determine available resources and clinical, educational, and collaborative needs. METHODS Members of the Pan-African Pediatric Surgical Association (PAPSA) and the Global Pediatric Surgery Network (GPSN) completed a structured email survey covering PS providers, facilities, resources, workload, education/training, disease patterns, and collaboration priorities. RESULTS Of 288 deployed surveys, 96 were completed (33%) from 26 countries (45% of African countries). Median PS providers/million included 1 general surgeon and 0.26 pediatric surgeons. Median pediatric facilities/million included 0.03 hospitals, 0.06 ICUs, and 0.17 surgical wards. Neonatal ventilation was available in 90% of countries, fluoroscopy in 70%, TPN in 50%, and frozen section pathology in 35%. Median surgical procedures/institution/year was 852. Median waiting time was 40days for elective procedures and 7 days? for emergencies. Weighted average percent mortality for key surgical conditions varied between 1% (Sierra Leone) and 54% (Burkina Faso). Providers ranked collaborative professional development highest and direct clinical care lowest priority in projects with high-income partners. CONCLUSIONS The broad deficits identified in PS human and material resources in Africa suggest the need for a global collaborative effort to address the PS gaps. LEVEL OF EVIDENCE Level 5, expert opinion without explicit critical appraisal.
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18
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Ednie AC, Amram O, Creaser JC, Schuurman N, Leclerc S, Yanchar N. Hypertrophic pyloric stenosis in the Maritimes: examining the waves of change over time. Can J Surg 2017; 59:383-390. [PMID: 27669400 DOI: 10.1503/cjs.002816] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Changing patterns of referral and management of pediatric surgical conditions, including hypertrophic pyloric stenosis (HPS), have recently been described and often relate to comfort with early nonoperative management, anesthesia and corrective surgery. Travelling distance required for treatment at pediatric centres can also be burdensome for families. We assessed referral patterns for HPS in the maritime provinces of Canada over 10 years to quantify the burden on families travelling for surgical care. METHODS We reviewed the charts of all patients with HPS in the Maritimes. Length of hospital stay (LOS) and complication rates were analyzed in regards to resuscitation and management at a pediatric centre and/or peripheral centres. We used postal codes for each patient to track distance travelled for management. RESULTS We assessed 751 cases of HPS. During the study period (Jan. 1, 2001-Dec. 31, 2010), referral to pediatric centres increased from 49% to 71%. Postoperative complications were 2.5-fold higher in peripheral centres. Infants referred to pediatric centres were 78% less likely to have an LOS longer than 3 days. Laparoscopic pyloromyotomy, which was performed only in pediatric centres, was associated with a shorter postoperative LOS. CONCLUSION Our study supports the current literature demonstrating improved outcomes, shorter overall LOS and decreased risk of complications when infants with HPS are treated in pediatric centres. This should be considered when planning access to pediatric surgical resources.
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Affiliation(s)
- Alexander C Ednie
- From the Department of General Surgery, Dalhousie University, Halifax, NS (Ednie); the Department of Medicine, Division of AIDS, University of British Columbia, Vancouver, BC (Amram); the Epidemiology and Population Health Program, BC Centre for Excellence in HIV/AIDS, Vancouver, BC (Amram); the University of British Columbia, Vancouver, BC (Creaser); the Department of Geography, Simon Fraser University, Vancouver, BC (Schuurman); the Department of Pediatric Surgery, Centre Hospitalier Universitaire de Queébec, Québec, Que. (Leclerc); the Departments of Surgery and Community Health and Epidemiology, Dalhousie University, Halifax, NS (Yanchar); and the Department of Pediatric General Surgery, IWK Health Centre, Halifax, NS (Yanchar)
| | - Ofer Amram
- From the Department of General Surgery, Dalhousie University, Halifax, NS (Ednie); the Department of Medicine, Division of AIDS, University of British Columbia, Vancouver, BC (Amram); the Epidemiology and Population Health Program, BC Centre for Excellence in HIV/AIDS, Vancouver, BC (Amram); the University of British Columbia, Vancouver, BC (Creaser); the Department of Geography, Simon Fraser University, Vancouver, BC (Schuurman); the Department of Pediatric Surgery, Centre Hospitalier Universitaire de Queébec, Québec, Que. (Leclerc); the Departments of Surgery and Community Health and Epidemiology, Dalhousie University, Halifax, NS (Yanchar); and the Department of Pediatric General Surgery, IWK Health Centre, Halifax, NS (Yanchar)
| | - Jenna Colleen Creaser
- From the Department of General Surgery, Dalhousie University, Halifax, NS (Ednie); the Department of Medicine, Division of AIDS, University of British Columbia, Vancouver, BC (Amram); the Epidemiology and Population Health Program, BC Centre for Excellence in HIV/AIDS, Vancouver, BC (Amram); the University of British Columbia, Vancouver, BC (Creaser); the Department of Geography, Simon Fraser University, Vancouver, BC (Schuurman); the Department of Pediatric Surgery, Centre Hospitalier Universitaire de Queébec, Québec, Que. (Leclerc); the Departments of Surgery and Community Health and Epidemiology, Dalhousie University, Halifax, NS (Yanchar); and the Department of Pediatric General Surgery, IWK Health Centre, Halifax, NS (Yanchar)
| | - Nadine Schuurman
- From the Department of General Surgery, Dalhousie University, Halifax, NS (Ednie); the Department of Medicine, Division of AIDS, University of British Columbia, Vancouver, BC (Amram); the Epidemiology and Population Health Program, BC Centre for Excellence in HIV/AIDS, Vancouver, BC (Amram); the University of British Columbia, Vancouver, BC (Creaser); the Department of Geography, Simon Fraser University, Vancouver, BC (Schuurman); the Department of Pediatric Surgery, Centre Hospitalier Universitaire de Queébec, Québec, Que. (Leclerc); the Departments of Surgery and Community Health and Epidemiology, Dalhousie University, Halifax, NS (Yanchar); and the Department of Pediatric General Surgery, IWK Health Centre, Halifax, NS (Yanchar)
| | - Suzanne Leclerc
- From the Department of General Surgery, Dalhousie University, Halifax, NS (Ednie); the Department of Medicine, Division of AIDS, University of British Columbia, Vancouver, BC (Amram); the Epidemiology and Population Health Program, BC Centre for Excellence in HIV/AIDS, Vancouver, BC (Amram); the University of British Columbia, Vancouver, BC (Creaser); the Department of Geography, Simon Fraser University, Vancouver, BC (Schuurman); the Department of Pediatric Surgery, Centre Hospitalier Universitaire de Queébec, Québec, Que. (Leclerc); the Departments of Surgery and Community Health and Epidemiology, Dalhousie University, Halifax, NS (Yanchar); and the Department of Pediatric General Surgery, IWK Health Centre, Halifax, NS (Yanchar)
| | - Natalie Yanchar
- From the Department of General Surgery, Dalhousie University, Halifax, NS (Ednie); the Department of Medicine, Division of AIDS, University of British Columbia, Vancouver, BC (Amram); the Epidemiology and Population Health Program, BC Centre for Excellence in HIV/AIDS, Vancouver, BC (Amram); the University of British Columbia, Vancouver, BC (Creaser); the Department of Geography, Simon Fraser University, Vancouver, BC (Schuurman); the Department of Pediatric Surgery, Centre Hospitalier Universitaire de Queébec, Québec, Que. (Leclerc); the Departments of Surgery and Community Health and Epidemiology, Dalhousie University, Halifax, NS (Yanchar); and the Department of Pediatric General Surgery, IWK Health Centre, Halifax, NS (Yanchar)
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Increased pediatric sub-specialization is associated with decreased surgical complication rates for inpatient pediatric urology procedures. J Pediatr Urol 2016; 12:388.e1-388.e7. [PMID: 27363329 PMCID: PMC5161733 DOI: 10.1016/j.jpurol.2016.05.034] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Accepted: 05/16/2016] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Increased case volumes and training are associated with better surgical outcomes. However, the impact of pediatric urology sub-specialization on perioperative complication rates is unknown. OBJECTIVES To determine the presence and magnitude of difference in rates of common postoperative complications for elective pediatric urology procedures between specialization levels of urologic surgeons. The Nationwide Inpatient Sample (NIS), a nationally representative administrative database, was used. STUDY DESIGN The NIS (1998-2009) was retrospectively reviewed for pediatric (≤18 years) admissions, using ICD-9-CM codes to identify urologic surgeries and National Surgical Quality Improvement Program (NSQIP) inpatient postoperative complications. Degree of pediatric sub-specialization was calculated using a Pediatric Proportion Index (PPI), defined as the ratio of children to total patients operated on by each provider. The providers were grouped into PPI quartiles: Q1, 0-25% specialization; Q2, 25-50%; Q3, 50-75%; Q4, 75-100%. Weighted multivariate analysis was performed to test for associations between PPI and surgical complications. RESULTS A total of 71,479 weighted inpatient admissions were identified. Patient age decreased with increasing specialization: Q1, 7.9 vs Q2, 4.8 vs Q3, 4.8 vs Q4, 4.6 years, P < 0.01). Specialization was not associated with race (P > 0.20), gender (P > 0.50), or comorbidity scores (P = 0.10). Mortality (1.5% vs 0.2% vs 0.3% vs 0.4%, P < 0.01) and complication rates (15.5% vs 11.7% vs 9.6% vs 10.9%, P < 0.0001) both decreased with increasing specialization. Patients treated by more highly specialized surgeons incurred slightly higher costs (Q2, +4%; Q3, +1%; Q4 + 2%) but experienced shorter length of hospital stay (Q2, -5%; Q3, -10%; Q4, -3%) compared with the least specialized providers. A greater proportion of patients treated by Q1 and Q3 specialized urologists had CCS ≥2 than those seen by Q2 or Q4 urologists (12.5% and 12.2%, respectively vs 8.4% and 10.9%, respectively, P = 0.04). Adjusting for confounding effects, increased pediatric specialization was associated with decreased postoperative complications: Q2 OR 0.78, CI 0.58-1.05; Q3 OR 0.60, CI 0.44-0.84; Q4 OR 0.70, CI 0.58-0.84; P < 0.01. DISCUSSION Providers with proportionally higher volumes of pediatric patients achieved better postoperative outcomes than their less sub-specialized counterparts. This may have arisen from increased exposure to pediatric anatomy and physiology, and greater familiarity with pediatric techniques. LIMITATION The NIS admission-based retrospective design did not enable assessment of long-term outcomes, repeated admissions, or to track a particular patient across time. The study was similarly limited in evaluating the effect of pre-surgical referral patterns on patient distributions. CONCLUSIONS Increased pediatric sub-specialization among urologists was associated with a decreased risk of mortality and surgical complications in children undergoing inpatient urologic procedures.
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Kim Y, Jung K, Ryu YJ, Moon SB. Pediatric appendectomy: the outcome differences between pediatric surgeons and general surgeons. Surg Today 2016; 46:1181-6. [PMID: 27142973 DOI: 10.1007/s00595-016-1343-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Accepted: 11/19/2015] [Indexed: 11/28/2022]
Abstract
PURPOSE The aim of this study was to review our experience of pediatric appendectomy performed by either a general surgeon (GS) or a pediatric surgeon (PS) to determine any differences in outcomes. METHODS We reviewed the medical records of pediatric appendicitis patients, 4 years before (GS group, 2007-2010) and after (PS group, 2011-2014) the introduction of a pediatric surgical practice. The records were reviewed for the following variables: operation time, length of hospital stay, complications, readmission in ≤30 days, type of operation, negative for appendicitis, drainage, open conversion, and reoperation in ≤30 days. RESULTS Over 8 years, 400 patients were operated on for acute appendicitis, with the PS group comprising 61 % (N = 244) of patients. The operation time (55.1 vs 43.2 min, p = 0.0001) and postoperative length of hospital stay (3.5 vs 2.7 days, p = 0.001) were shorter, more patients were treated by laparoscopy (61.3 vs 91.2 %, p = 0.0001), and a fewer patients required peritoneal drainage (29.5 vs 63.2 %, p = 0.023) in the PS group than in the GS group. The negative appendectomy rate was slightly lower in the PS group, but not to a statistically significant degree. CONCLUSION The patients in the PS group enjoyed a reduced operation time and length of hospital stay, greater likelihood of laparoscopic operation, and less peritoneal drainage than the patients in the GS group.
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Affiliation(s)
- Younglim Kim
- Department of Surgery, Kangwon National University School of Medicine, Chuncheon, 200-722, South Korea
| | - Kyuwhan Jung
- Department of Surgery, Seoul National University Bundang Hospital, Songnam, South Korea
| | - Young-Joon Ryu
- Department of Pathology, Kangwon National University School of Medicine, Chuncheon, South Korea
| | - Suk-Bae Moon
- Department of Surgery, Kangwon National University School of Medicine, Chuncheon, 200-722, South Korea.
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Pediatric Emergency Appendectomy and 30-Day Postoperative Outcomes in District General Hospitals and Specialist Pediatric Surgical Centers in England, April 2001 to March 2012. Ann Surg 2016; 263:184-90. [DOI: 10.1097/sla.0000000000001099] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Assessment of variation in care and outcomes for pediatric appendicitis at children's and non-children's hospitals. J Pediatr Surg 2015; 50:1885-92. [PMID: 26190133 DOI: 10.1016/j.jpedsurg.2015.06.012] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2015] [Revised: 05/21/2015] [Accepted: 06/07/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND Variation in care may indicate an opportunity for quality improvement and to decrease waste. Variation in appendicitis practice, resource use, and costs have not been well studied at non-children's hospitals (NCHs) where most children undergo care. The purpose of this study was to quantify variation in care for perforated pediatric appendicitis within and between children's hospitals (CHs) and NCH. METHODS Using the 2012 Kids' Inpatient Database, 11,216 children with perforated appendicitis were identified. Comparisons between CH and NCH were made in regard to operative approach (open versus laparoscopic), central line (CL) and total parenteral nutrition (PN) use, complication rates, length of stay (LOS), and total costs. RESULTS NCHs cared for 8051 patients (72%) with perforated appendicitis. CHs were more likely to perform a laparoscopy compared to NCHs (odds ratio (OR) 10.2, 95% confidence interval (95% CI) 5.7-18.2), and to utilize CL or PN than NCHs (CL OR 2.4 (95% CI 1.5-3.8), PN OR 2.6 (95% CI 1.4-4.9)). Composite complication rates were lower at CH (OR 0.5 (95% CI 0.4-0.6)). While LOS was not different between CH and NCH in the fully adjusted model, costs were higher at CH (OR 6.8 (95% CI 3.9-12.2)). Low and high outliers could be identified for each variable and outcome of interest with no consistent performance regardless of CH or NCH status. CONCLUSIONS Variation in operative approach, resource use, complications, LOS, and costs exist in the management of pediatric perforated appendicitis with greatest variation observed at NCH. Future quality improvement efforts should be tailored for implementation at both CH and high-volume NCH.
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Putnam LR, Nguyen LK, Lally KP, Franzini L, Tsao K, Austin MT. A statewide analysis of specialized care for pediatric appendicitis. Surgery 2015; 158:787-92. [DOI: 10.1016/j.surg.2015.05.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2015] [Revised: 04/13/2015] [Accepted: 05/18/2015] [Indexed: 11/15/2022]
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Healy DA, Doyle D, Moynagh E, Maguire M, Ahmed I, Ahmed AS, Caldwell M, O'Hanrahan T, Walsh SR. Systematic Review and Meta-Analysis on the Influence of Surgeon Specialization on Outcomes Following Appendicectomy in Children. Medicine (Baltimore) 2015; 94:e1352. [PMID: 26266388 PMCID: PMC4616707 DOI: 10.1097/md.0000000000001352] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The aim of this study is to assess the influence of surgeon specialization on outcomes following appendicectomy in children.General surgeons and pediatric surgeons manage appendicitis in children; however, the influence of subspecialization on outcomes remains unclear.Two authors searched Medline and Embase to identify relevant studies. Eligible studies were comparative and provided data on children who had appendicectomy while under the care of general or pediatric surgical teams. Two authors initially screened titles and abstracts and then full text manuscripts were evaluated. Data were extracted by 2 authors using an electronic spreadsheet. Pooled risk ratios and pooled mean differences were used in analyses.We identified 9 relevant studies involving 50,963 children who were managed by general surgery teams and 15,032 children who were managed by pediatric surgery teams. A normal appendix was removed in 4660/48,105 children treated by general surgery units and in 889/14,760 children treated by pediatric units (pooled risk ratio 1.79; 95% confidence interval [CI] 1.26-2.54; P = 0.001). Children managed in general units had shorter mean hospital stays compared with children managed in pediatric units (pooled mean difference -0.70 days; 95%CI -1.09 to -0.30; P = 0.0005). There were no significant differences regarding wound infections, intra-abdominal abscesses, readmissions, or mortality.We found that children who were managed by specialized pediatric surgery teams had lower rates of negative appendicectomy although mean length of stay was longer. Our article is based upon a group of heterogeneous and mostly retrospective studies and therefore there is little external validity. Further studies are needed.
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Affiliation(s)
- Donagh A Healy
- From the Department of General Surgery, The Mall, Sligo Regional Hospital, Sligo (DAH, DD, EM, MM, IA, ASA, MC, TO); and Department of Surgery, National University of Ireland Galway, Galway, Ireland (SRW)
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Determinants of postoperative abscess occurrence and percutaneous drainage in children with perforated appendicitis. Pediatr Surg Int 2014; 30:1265-71. [PMID: 25362478 DOI: 10.1007/s00383-014-3617-4] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/07/2014] [Indexed: 01/07/2023]
Abstract
PURPOSE Postoperative abscesses after perforated appendicitis have no clear risk factors or indications for percutaneous drainage. Our study addressed these two issues. METHODS A logistic regression model was used to delineate risk factors for postoperative abscess in children with perforated appendicitis treated during a recent 5-year period. Drainage of abscess was compared to antibiotic treatment. RESULTS Postoperative abscess occurred in 42 (14.8%) of 284 patients. Higher WBC count, presence of bowel obstruction at presentation, diffuse peritonitis with a dominant abscess at surgery, and one specific surgeon were significantly associated with postoperative abscess, while fever or pain requiring narcotics at the time of abscess diagnosis was significantly associated with drainage. Compared to non-drainage, those drained had longer hospital stay including readmissions (15.9 ± 5.3 vs. 12.2 ± 4.6 days, p < 0.005) and less readmissions (9.5 vs. 33.3%, p = 0.06). Over the 5-year period, there was no increased trend in abscess occurrence (p = 0.56), but there was an increased trend in the use of percutaneous drainage (p = 0.02). CONCLUSIONS The risk of a postoperative abscess can be predicted by specific clinical characteristics, surgical findings, and treatment-related factors. Percutaneous drainage was associated with longer hospital stays, but less readmissions.
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Variation in Practice and Resource Utilization Associated With the Diagnosis and Management of Appendicitis at Freestanding Children's Hospitals. Ann Surg 2014; 259:1228-34. [PMID: 24096770 DOI: 10.1097/sla.0000000000000246] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Goldin AB, Dasgupta R, Chen LE, Blakely ML, Islam S, Downard CD, Rangel SJ, St Peter SD, Calkins CM, Arca MJ, Barnhart DC, Saito JM, Oldham KT, Abdullah F. Optimizing resources for the surgical care of children: an American Pediatric Surgical Association Outcomes and Clinical Trials Committee consensus statement. J Pediatr Surg 2014; 49:818-22. [PMID: 24851778 DOI: 10.1016/j.jpedsurg.2014.02.085] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Revised: 02/16/2014] [Accepted: 02/17/2014] [Indexed: 10/25/2022]
Abstract
The United States' healthcare system is facing unprecedented pressures: the healthcare cost curve is not sustainable while the bar of standards and expectations for the quality of care continues to rise. Systems committed to the surgical treatment of children will likely require changes and reorganization. Regardless of these mounting pressures, hospitals must remain focused on providing the best possible care to each child at every encounter. Available clinical expertise and hospital resources should be optimized to match the complexity of the treated condition. Although precise criteria are lacking, there is a growing consensus that the optimal combination of clinical experience and hospital resources must be defined, and efforts toward this goal have been supported by the Regents of the American College of Surgeons, the members of the American Pediatric Surgical Association, and the Society for Pediatric Anesthesia (SPA) Board of Directors. The topic of optimizing outcomes and the discussion of the concepts involved have unfortunately become divisive. Our goals, therefore, are 1) to provide a review of the literature that can provide context for the discussion of regionalization, volume, and optimal resources and promote mutual understanding of these important terms, 2) to review the evidence that has been published to date in pediatric surgery associated with regionalization, volume, and resource, 3) to focus on a specific resource (anesthesia), and the association that this may have with outcomes, and 4) to provide a framework for future research and policy efforts.
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Affiliation(s)
- Adam B Goldin
- Division of Pediatric General and Thoracic Surgery, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA 98105.
| | - Roshni Dasgupta
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital, Cincinnati, OH 45229-3039
| | - Li Ern Chen
- Division of Pediatric Surgery, University of Texas Southwestern Medical Center, Children's Medical Center, Dallas, TX 75235
| | - Martin L Blakely
- Department of Pediatric Surgery, Vanderbilt University Medical Center, Nashville, TN 37232
| | - Saleem Islam
- Division of Pediatric Surgery, University of Florida College of Medicine, Gainesville, FL 32610
| | - Cynthia D Downard
- Division of Pediatric Surgery, Hiram C. Polk, Jr. M.D. Department of Surgery, University of Louisville, Louisville, KY 40202
| | - Shawn J Rangel
- Department of Pediatric Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115
| | - Shawn D St Peter
- Department of Surgery, Children's Mercy Hospital, Kansas City, MO 64108
| | - Casey M Calkins
- Department of Pediatric Surgery, Medical College of Wisconsin, Children's Hospital of Wisconsin, Milwaukee, WI 53226
| | - Marjorie J Arca
- Department of Pediatric Surgery, Medical College of Wisconsin, Children's Hospital of Wisconsin, Milwaukee, WI 53226
| | - Douglas C Barnhart
- Division of Pediatric Surgery, University of Utah, Salt Lake City, UT 84113
| | - Jacqueline M Saito
- Division of Pediatric Surgery, Washington University, St. Louis, MO 63110
| | - Keith T Oldham
- Department of Pediatric Surgery, Medical College of Wisconsin, Children's Hospital of Wisconsin, Milwaukee, WI 53226
| | - Fizan Abdullah
- Division of Pediatric Surgery, Johns Hopkins University, Baltimore, MD 21287
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Cheong LHA, Emil S. Determinants of appendicitis outcomes in Canadian children. J Pediatr Surg 2014; 49:777-81. [PMID: 24851769 DOI: 10.1016/j.jpedsurg.2014.02.074] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2014] [Accepted: 02/13/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Outcomes of appendicitis may be influenced by access to healthcare. We investigated the determinants of pediatric appendicitis outcomes in the single-payer Canadian healthcare system. METHODS Children coded for urgent appendectomy by the Canadian Institute of Health Information during the period 2004-2010 were analyzed. Misdiagnosis rate, perforated appendicitis rate, and hospital stay were the outcomes studied. Analyzed variables included age, gender, domicile, socioeconomic status, surgeon's specialty, hospital type, region, and operative approach. Logistic regression analysis was used to examine associations, and a quintile regression model examined the effect on median hospital stay. RESULTS 41,702 patients were studied. A higher rate of perforated appendicitis was associated with lower age [OR 2.66], male gender [OR 1.18], pediatric surgeon [OR 1.25], and treatment outside the Maritimes. A higher rate of misdiagnosis was associated with lower age [OR 1.53], female gender [OR 2.29], non-children's hospital [OR 1.33], and western Canada [OR 1.22]. A significantly longer hospital stay was associated with open appendectomy, pediatric surgeon, and the Territories for simple appendicitis, and open appendectomy, pediatric surgeon, children's hospital, and the Maritimes for perforated appendicitis. CONCLUSIONS In Canada, outcomes of pediatric appendicitis are associated with regional and treatment-level factors. Rural domicile and socioeconomic status do not affect outcomes.
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Affiliation(s)
- Li Hsia Alicia Cheong
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre
| | - Sherif Emil
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre.
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Tiboni S, Bhangu A, Hall NJ. Outcome of appendicectomy in children performed in paediatric surgery units compared with general surgery units. Br J Surg 2014; 101:707-14. [PMID: 24700440 DOI: 10.1002/bjs.9455] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/14/2014] [Indexed: 11/11/2022]
Abstract
BACKGROUND Appendicectomy for acute appendicitis in children may be performed in specialist centres by paediatric surgeons or in general surgery units. Service provision and outcome of appendicectomy in children may differ between such units. METHODS This multicentre observational study included all children (aged less than 16 years) who had an appendicectomy at either a paediatric surgery unit or general surgery unit. The primary outcome was normal appendicectomy rate (NAR). Secondary outcomes included 30-day adverse events, use of ultrasound imaging and laparoscopy, and consultant involvement in procedures. RESULTS Appendicectomies performed in 19 paediatric surgery units (242 children) and 54 general surgery units (461 children) were included. Children treated in paediatric surgery units were younger and more likely to have a preoperative ultrasound examination, a laparoscopic procedure, a consultant present at the procedure, and histologically advanced appendicitis than children treated in general surgery units. The unadjusted NAR was significantly lower in paediatric surgery units (odds ratio (OR) 0.37, 95 per cent confidence interval 0.23 to 0.59; P < 0.001), and the difference persisted after adjusting for age, sex and use of preoperative ultrasound imaging (OR 0.34, 0.21 to 0.57; P < 0.001). Female sex and preoperative ultrasonography, but not age, were significantly associated with normal appendicectomy in general surgery units but not in paediatric surgery units in this adjusted model. The unadjusted 30-day adverse event rate was higher in paediatric surgery units than in general surgery units (OR 1.90, 1.18 to 3.06; P = 0.011). When adjusted for case mix and consultant presence at surgery, no statistically significant relationship between centre type and 30-day adverse event rate existed (OR 1.59, 0.93 to 2.73; P = 0.091). CONCLUSION The NAR in general surgery units was over twice that in paediatric surgery units. Despite a more severe case mix, paediatric surgery units had a similar 30-day adverse event rate to general surgery units. Service provision differs between paediatric and general surgery units.
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Affiliation(s)
- S Tiboni
- Addenbrooke's Hospital, Cambridge, India
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da Silva PSL, de Aguiar VE, Waisberg J. Pediatric surgeon vs general surgeon: does subspecialty training affect the outcome of appendicitis? Pediatr Int 2014; 56:248-53. [PMID: 24004383 DOI: 10.1111/ped.12208] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2013] [Revised: 07/24/2013] [Accepted: 08/26/2013] [Indexed: 12/01/2022]
Abstract
BACKGROUND The absence of pediatric surgeons in many centers results in restriction of patient access to pediatric subspecialty care. The aim of this study was to compare the outcomes of children treated for appendicitis by pediatric surgeons (PS) and by general surgeons (GS). METHODS This was a retrospective review of the charts of all consecutive patients <16 years old who underwent appendectomy during 2 years The primary outcome measure was the overall rate of complications. Secondary outcome measures included length of hospital stay (LOS), symptom duration, time from emergency department diagnosis to surgery, and readmission rate within 30 days. RESULTS A total of 94 patients (PS group, n = 66; GS group, n = 28) were included. PS patients were younger. For patients with complicated appendicitis, complications were significantly more prevalent in the GS group (57% vs 15%; P = 0.0001). Median LOS was not significantly different between the two groups for complicated appendicitis, but patients with non-complicated appendicitis had a significant longer LOS when treated by PS (3.74 ± 1.5 vs 2.57 ± 1.21 days; P = 0.0041). Patients in the PS group had a prolonged use of antibiotics (2 vs 4 days; P = 0.001), and longer LOS (3 vs 4 days; P = 0.0018). CONCLUSIONS Overall complication rates were similar between PS and GS. Complications were significantly more prevalent in patients with complicated appendicitis who were treated by GS.
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Affiliation(s)
- Paulo Sérgio Lucas da Silva
- Pediatric Intensive Care Unit, Department of Pediatrics, Hospital do Servidor Público Municipal (HSPM), São Paulo, Brazil
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Adwan H, Weerasuriya CK, Endleman P, Barnes A, Stewart L, Justin T. Laparoscopic versus open appendicectomy in children: a UK District General Hospital experience. J Pediatr Surg 2014; 49:277-9. [PMID: 24528966 DOI: 10.1016/j.jpedsurg.2013.11.039] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2013] [Accepted: 11/10/2013] [Indexed: 11/17/2022]
Abstract
AIMS The aim of this study was to evaluate the potential role of laparoscopic appendicectomy in reducing morbidity and length of stay in children compared to open procedures in a UK District General Hospital setting. METHODS A three-year retrospective review of children ≤ 15 years with histologically confirmed appendicitis who underwent laparoscopic (LA) and/or open (OA) appendicectomy was performed. Choice of operation was based on individual surgeon's preference and on patient's body size. Data collected included rate of histologically complicated appendicitis, post-operative length of stay (LOS), and collective and differential morbidity rates, i.e., wound infection, intra-abdominal collection, and ileus. Chi-square and Mann-Whitney tests were used for statistical analysis. P<0.05 was regarded as significant. RESULTS Eighty children (70% male) were identified at median age 11 (3-15) years. They could be divided into complicated (n=18, 22%) and simple appendicitis (n=62, 78%). Appendicectomy was performed in all as an OPEN (n=53, 66%) or LAPAROSCOPIC (n=27, 34%) procedure. Both groups were comparable in gender distribution (P=0.11) and rate of complicated appendicitis (30% vs. 19%, respectively; P=0.27). Median age was significantly lower in the OPEN group [10 (3-15) vs. 12 (7-15) years; P<0.004]. Laparoscopic appendicectomy had a significantly lower rate of collective morbidity (3.8% vs. 25.9%; P<0.003), including lower rate of intra-abdominal collection (1.9% vs. 14.8%; P<0.01). Median LOS was not significantly different (1 day vs. 2 days; P=0.14). CONCLUSION Laparoscopic appendicectomy in children in a UK District General Hospital is safe and was associated with significantly less post-operative morbidity than the open technique.
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Affiliation(s)
- Hussamuddin Adwan
- West Suffolk Hospital NHS Foundation Trust, Bury St Edmunds, Suffolk, UK.
| | | | - Phillip Endleman
- West Suffolk Hospital NHS Foundation Trust, Bury St Edmunds, Suffolk, UK
| | - Alice Barnes
- West Suffolk Hospital NHS Foundation Trust, Bury St Edmunds, Suffolk, UK
| | - Lara Stewart
- West Suffolk Hospital NHS Foundation Trust, Bury St Edmunds, Suffolk, UK
| | - Timothy Justin
- West Suffolk Hospital NHS Foundation Trust, Bury St Edmunds, Suffolk, UK.
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Shifts towards pediatric specialists in the treatment of appendicitis and pyloric stenosis: trends and outcomes. J Pediatr Surg 2014; 49:123-7; discussion 127-8. [PMID: 24439595 DOI: 10.1016/j.jpedsurg.2013.09.046] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2013] [Accepted: 09/30/2013] [Indexed: 11/22/2022]
Abstract
BACKGROUND Little data exists on temporal changes in the care of children with common surgical conditions. We hypothesized that an increasing proportion of procedures are performed at pediatric hospitals over time, and that outcomes are superior at these centers. METHODS We conducted a retrospective cohort study using Washington State discharge records for children 0-17years old undergoing appendectomy (n=39,472) or pyloromyotomy (n=3,500). Pediatric hospitals were defined as centers with full-time pediatric surgeons. Outcomes were examined for two time periods (1987-2000, 2001-2009). RESULTS From 1987 to 2009, the proportion of procedures performed at pediatric hospitals steadily increased. The percentage for appendectomies increased from 17% to 32%, and that for pyloromyotomies increased from 57% to 99%. For pyloromyotomy, care at a pediatric hospital was associated with decreased risk of postoperative complications (OR=0.36, p<0.001) for both time periods. Appendectomy outcomes did not differ significantly in the early time period, but in the later time period specialist care was associated with lower risk of complications in children <5years (OR=0.54, p=0.03). CONCLUSION There has been a shift towards pediatric hospitals for certain procedures, with a widening disparity in outcomes for younger children. These results suggest that procedures in younger patients may best be performed by providers familiar with these patient populations.
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Rhee D, Papandria D, Yang J, Zhang Y, Ortega G, Colombani PM, Chang DC, Abdullah F. Comparison of pediatric surgical outcomes by the surgeon's degree of specialization in children. J Pediatr Surg 2013; 48:1657-63. [PMID: 23932603 DOI: 10.1016/j.jpedsurg.2012.12.048] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2012] [Revised: 12/03/2012] [Accepted: 12/27/2012] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Improved surgical outcomes in children have been associated with pediatric surgical specialization, previously defined by surgeon operative volume or fellowship training. The present study evaluates pediatric surgical outcomes through classifying surgeons by degrees of pediatric versus adult operative experience. METHODS A cross-sectional study was performed using nationally representative hospital discharge data from 1998 to 2007. Patients under 18 years of age undergoing inpatient operations in neurosurgery, otolaryngology, cardiothoracic, general surgery, orthopedic surgery, and urology were included. An index was created, calculating the proportion of children treated by each surgeon. In-hospital mortality and length of stay were compared by index quartiles. Multivariate analysis was adjusted for patient and hospital characteristics. RESULTS A total of 119,164 patients were operated on by 13,141 surgeons. Within cardiothoracic surgery, there were 1.78 (p=0.02) and 2.61 (p<0.01) increased odds of mortality comparing surgeons in the lowest two quartiles for pediatric specialization respectively with the highest quartile. For general surgery, a 2.15 (p=0.04) increase in odds for mortality was found when comparing surgeons between the lowest and the highest quartiles. Comparing the least to the most specialized surgeons, length of stay increased 1.14 days (p=0.02) for cardiothoracic surgery, 0.58 days (p=0.04) for neurosurgery, 0.23 days (p=0.02) for otolaryngology, and decreased by 1.06 days (p<0.01) for orthopedic surgery. CONCLUSION The present study demonstrates that surgeons caring preferentially for children-as a proportion of their overall practice-generally have improved mortality outcomes in general and cardiothoracic surgery. These data suggest a benefit associated with increased referral of children to pediatric practitioners, but further study is required.
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Affiliation(s)
- Daniel Rhee
- Department of Surgery, Division of Pediatric Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287-0005, USA
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Variation in Risk-Adjusted Hospital Readmission After Treatment of Appendicitis at 38 Children's Hospitals. Ann Surg 2013; 257:758-65. [DOI: 10.1097/sla.0b013e318268a663] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Dennett KV, Tracy S, Fisher S, Charron G, Zurakowski D, Calvert CE, Chen C. Treatment of perforated appendicitis in children: what is the cost? J Pediatr Surg 2012; 47:1177-84. [PMID: 22703790 DOI: 10.1016/j.jpedsurg.2012.03.024] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2012] [Accepted: 03/06/2012] [Indexed: 12/14/2022]
Abstract
BACKGROUND/PURPOSE We compared direct hospital costs and indirect costs to the family associated with immediate appendectomy or initial nonoperative management for perforated appendicitis in children. METHODS From June 2009 through May 2010, 61 prospectively identified families completed a cost diary, documenting the numbers of missed school days for the child and missed employment days for the adult caregiver(s) over the treatment course. Hospital costs were obtained from hospital financial databases. Mann-Whitney U tests and Fisher exact tests were used to compare outcome measures for each treatment strategy. RESULTS Patients treated by initial nonoperative management had a significantly longer median length of stay (9 days vs 7 days, P = .02) and a significantly greater median total hospital cost per patient ($31,349 vs $21,323, P = .01) when compared with those treated by immediate appendectomy. There was no significant difference in median number of missed school days (9 days vs 10 days, P = .23) or missed employment days for adult caregiver(s) (5 days vs 7 days, P = .18) between treatment strategies. CONCLUSIONS Patients with perforated appendicitis treated by initial nonoperative management had a greater length of stay and a significantly greater total hospital cost but were not burdened by significantly greater indirect costs compared with those treated by immediate appendectomy.
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Affiliation(s)
- Kate V Dennett
- Department of Surgery, Children's Hospital, 300 Longwood Ave, Boston, MA 02115, USA
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Mizrahi I, Mazeh H, Levy Y, Karavani G, Ghanem M, Armon Y, Vromen A, Eid A, Udassin R. Comparison of pediatric appendectomy outcomes between pediatric surgeons and general surgery residents. J Surg Res 2012; 180:185-90. [PMID: 22578857 DOI: 10.1016/j.jss.2012.04.021] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2012] [Revised: 03/27/2012] [Accepted: 04/11/2012] [Indexed: 11/16/2022]
Abstract
BACKGROUND Appendectomy is the most common urgent procedure in children, and surgical outcomes may be affected by the surgeon's experience. This study's aim is to compare appendectomy outcomes performed by pediatric surgeons (PSs) and general surgery residents (GSRs). MATERIALS AND METHODS A retrospective review of all patients younger than 16y treated for appendicitis at two different campuses of the same institution during the years 2008-2009 was performed. Appendectomies were performed by PS in one campus and GSR in the other. Primary end points included postoperative morbidity and hospital length of stay. RESULTS During the study period, 246 (61%) patients were operated by senior GSR (postgraduate year 5-7) versus 157 (39%) patients by PS. There was no significant difference in patients' characteristics at presentation to the emergency room and the rate of appendeceal perforation (11% versus 15%, P=0.32), and noninfectious appendicitis (5% versus 5% P=0.78) also was similar. Laparoscopic surgery was performed more commonly by GSR (16% versus 9%, P=0.02) with shorter operating time (54±1.5 versus 60±2.1, P=0.01). Interestingly, the emergency room to operating room time was shorter for GSR group (419±14 versus 529±24min, P<0.001). The hospital length of stay was shorter for the GSR group (4.0±0.2 versus 4.5±0.2, P=0.03), and broad-spectrum antibiotics were used less commonly (20% versus 53%, P<0.0001) and so was home antibiotics continuation (13% versus 30%, P<0.0001). Nevertheless, postoperative complication rate was similar (5% versus 7%, P=0.29) and so was the rate of readmissions (2% versus 5%, P=0.52). CONCLUSIONS The results of this study suggest that the presence of a PS does not affect the outcomes of appendectomies.
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Affiliation(s)
- Ido Mizrahi
- Department of Surgery, Hadassah-Hebrew University Medical Center, Mount Scopus, Jerusalem, Israel
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Surgeon volume trumps specialty: outcomes from 3596 pediatric cholecystectomies. J Pediatr Surg 2012; 47:673-80. [PMID: 22498380 DOI: 10.1016/j.jpedsurg.2011.10.054] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2011] [Revised: 09/05/2011] [Accepted: 10/17/2011] [Indexed: 11/20/2022]
Abstract
BACKGROUND Laparoscopic cholecystectomy is the standard surgical management of biliary disease in children, but there has been a paucity of studies addressing outcomes after pediatric cholecystectomies, particularly on a national level. We conducted the first study to address the effect of surgeon specialty and volume on clinical and economic outcomes after pediatric cholecystectomies on a population level. METHODS We conducted a retrospective cross-sectional study using the Health Care Utilization Project Nationwide Inpatient Sample. Children (≤ 17 years) who underwent laparoscopic cholecystectomy from 2003 to 2007 were selected. Pediatric surgeons performed 90% or higher of their total cases in children. High-volume surgeons were in the top tertile (n ≥ 37 per year) of total cholecystectomies performed. χ(2), Analyses of variance, and multivariate linear and logistic regression analyses were used to assess in-hospital complications, median length of hospital stay (LOS), and total hospital costs (2007 dollars). RESULTS A total of 3596 pediatric cholecystectomies were included. Low-volume surgeons had more complications, longer LOS, and higher costs than high-volume surgeons. After adjustment in multivariate regression, surgeon volume, but not specialty, was an independent predictor of LOS and cost. CONCLUSIONS High-volume surgeons have better outcomes after pediatric cholecystectomy than low-volume surgeons. To optimize outcomes in children after cholecystectomy, surgeon volume and laparoscopic experience should be considered above surgeon specialty.
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Lee SL, Stark R, Yaghoubian A, Shekherdimian S, Kaji A. Does age affect the outcomes and management of pediatric appendicitis? J Pediatr Surg 2011; 46:2342-5. [PMID: 22152878 DOI: 10.1016/j.jpedsurg.2011.09.030] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2011] [Accepted: 09/03/2011] [Indexed: 11/18/2022]
Abstract
PURPOSE Although it is recognized that younger children have higher appendiceal perforation rates, little is known about the effect of age on postoperative morbidity. The purpose of this study was to determine whether age affects the outcome and management of pediatric appendicitis. METHODS A retrospective review of all patients 14 years and younger who were treated for appendicitis over a 10-year period was performed. Study outcomes included 30-day postoperative morbidity, use of laparoscopy, and length of hospitalization (LOH). Postoperative morbidity included rates of wound infection, postoperative abscess drainage, and readmission. Patients were categorized into 3 age groups: young (≤5 years), middle (6-9 years), and older (≥10 years). Data for univariate associations were analyzed using χ(2) and Wilcoxon rank sum tests and reported as medians with interquartile ranges (IQR). Study outcomes were also analyzed using multivariable regression. RESULTS Overall, 5894 patients were identified. Median age was 10.3 years (IQR 7.3-12.5), and 61% were boys. The perforation rate was highest for patients 5 years and younger (≤5 years, 51%; 6-9 years, 32%; ≥10 years, 27%; P < .0001). Multivariable analysis demonstrated that although the need for postoperative abscess drainage was greatest in older children (10-14 years), the readmission rate and LOH was highest in the youngest children (≤5 years). Wound infection rates were similar across all age groups. CONCLUSIONS Although older children had a higher risk of abscess drainage, younger children were more likely to have perforated appendicitis, be readmitted, and have longer LOH. Management of appendicitis differed according to age. Laparoscopic appendectomy was more frequently performed in older children, whereas the youngest children were more likely to be treated nonoperatively.
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Affiliation(s)
- Steven L Lee
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA 90509, USA.
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Evans C, van Woerden HC. The effect of surgical training and hospital characteristics on patient outcomes after pediatric surgery: a systematic review. J Pediatr Surg 2011; 46:2119-27. [PMID: 22075342 DOI: 10.1016/j.jpedsurg.2011.06.033] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2010] [Revised: 05/25/2011] [Accepted: 06/22/2011] [Indexed: 01/07/2023]
Abstract
BACKGROUND/PURPOSE A systematic review aimed to compare patient outcomes after (1) appendicectomy and (2) pyloromyotomy performed by different surgical specialties, surgeons with different annual volumes, and in different hospital types, to inform the debate surrounding children's surgery provision. METHODS Embase, Medline, Cochrane Library, and Health Management Information Consortium were searched from January 1990 to February 2010 to identify relevant articles. Further literature was sought by contacting experts, citation searching, and hand-searching appropriate journals. RESULTS Seventeen relevant articles were identified. These showed that (1) rates of wrongly diagnosed appendicitis were higher among general surgeons, but there were little differences in other outcomes and (2) outcomes after pyloromyotomy were superior in patients treated by specialist surgeons. Surgical specialty was a better predictor of morbidity than hospital type, and surgeons with higher operative volumes had better results. CONCLUSIONS Existing evidence is largely observational and potentially subject to selection bias, but general pediatric surgery outcomes were clearly dependent on operative volumes. Published evidence suggests that (1) pediatric appendicectomy should not be centralized because children can be managed effectively by general surgeons; (2) pyloromyotomy need not be centralized but should be carried out in children's units by appropriately trained surgeons who expect to see more than 4 cases per year.
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Affiliation(s)
- Ceri Evans
- Cardiff University School of Medicine, University Hospital of Wales, Heath Park, CF14 4XN Cardiff, UK.
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Context and significance of emergency department visits and readmissions after pediatric appendectomy. J Pediatr Surg 2011; 46:1918-22. [PMID: 22008328 DOI: 10.1016/j.jpedsurg.2011.04.012] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2011] [Revised: 04/13/2011] [Accepted: 04/14/2011] [Indexed: 11/24/2022]
Abstract
BACKGROUND The readmission rate after pediatric appendectomy is frequently reported in clinical outcomes studies and quality improvement initiatives without proper description. Our aim was to delineate the context and significance of these encounters. METHODS Patients (<18 years old) who underwent appendectomy for acute appendicitis at a tertiary children's hospital from January 2007 through June 2010 were reviewed. Emergency department (ED) visits and inpatient readmissions within 90 days were identified and classified as unrelated, related surgical complications, or potentially avoidable visits for minor related concerns. RESULTS Of 629 patients, 119 (18.9%) had 141 ED visits or readmissions within 90 days after discharge. Eighty-three (58.9%) encounters were limited to the ED, and 58 (41.1%) required inpatient hospitalization. Eighty-seven percent of encounters within the first 30 days after discharge, but only 26% of those occurring beyond 30 days, were related to the operation (P < .001). Overall, 45 (31.9%) ED visits or readmissions were totally unrelated to the appendectomy, 36 (25.5%) represented true surgical complications requiring inpatient hospitalization, and 60 (42.6%) were minor, potentially avoidable visits related to the appendectomy. Potentially avoidable encounters were more common in Spanish-speaking patients (P < .01). CONCLUSIONS Emergency department visits and inpatient readmissions after pediatric appendectomy are frequent but not uniformly indicative of surgical complications or suboptimal care. Opportunities exist to reduce avoidable ED visits related to minor postoperative concerns.
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Wood JH, Partrick DA, Barham HP, Bensard DD, Travers SH, Bruny JL, McIntyre RC. Pediatric thyroidectomy: a collaborative surgical approach. J Pediatr Surg 2011; 46:823-8. [PMID: 21616234 DOI: 10.1016/j.jpedsurg.2011.02.013] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2011] [Accepted: 02/11/2011] [Indexed: 10/18/2022]
Abstract
INTRODUCTION We have developed a collaborative approach to pediatric thyroid surgery, with operations performed at a children's hospital by a pediatric surgeon and an endocrine surgeon. We hypothesize that this strategy minimizes specialist-specific limitations and optimizes care of children with surgical thyroid disease. METHODS Data from all partial and total thyroidectomies performed by the pediatric-endocrine surgery team at a tertiary children's hospital between 1995 and 2009 were collected and analyzed retrospectively. Statistical analyses were performed with IBM SPSS software (SPSS, Chicago, IL). RESULTS Thirty-five children met the inclusion criteria (69% female; median age, 13 years; median follow-up, 1119 days). The indications for operation were thyroid nodule (71%), genetic abnormality with predisposition to thyroid malignancy (17%), multinodular goiter (5.7%), Grave disease (2.9%), and Hashimoto thyroiditis (2.9%). Sixteen children (46%) underwent thyroid lobectomy, and 19 children (54%) underwent total thyroidectomy. Median length of stay was 1 day (1 day after lobectomy vs 2 days after total thyroidectomy, P < .0001). There were 4 cases of transient hypocalcemia after total thyroidectomy, but there were no nerve injuries or other in-hospital complications in either group (overall complication rate, 11%). CONCLUSIONS For pediatric thyroidectomy and thyroid lobectomy, collaboration of high-volume endocrine and pediatric surgeons as well as pediatric endocrinologists at a dedicated pediatric medical center provides optimal surgical outcomes.
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Affiliation(s)
- James H Wood
- Department of Surgery, University of Colorado Denver School of Medicine, Aurora, CO, USA
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Comparison of childhood appendicitis management in the regional paediatric surgery unit and the district general hospital. J Pediatr Surg 2010; 45:300-2. [PMID: 20152340 DOI: 10.1016/j.jpedsurg.2009.10.079] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2009] [Accepted: 10/27/2009] [Indexed: 11/20/2022]
Abstract
BACKGROUND/PURPOSE Ongoing debate surrounds the future provision of general paediatric surgery. The aim of this study was to compare outcomes for childhood appendicitis managed in a district general hospital (DGH) and a regional paediatric surgical unit (RU). METHODS Data collected retrospectively for a 2-year period in a DGH were compared with data collected prospectively for 1 year in an RU, where appendicitis management is guided by a care pathway. Children aged 6 to 15 years were included. RESULTS Four hundred and two patients were included (DGH ,196; RU, 206). There were more cases of gangrenous/perforated appendicitis in the RU (P < .0001). In the DGH, fewer patients received preoperative antibiotics (P < .0001) or underwent preoperative pain scoring (P < .0001). When adjusted for case mix, the relative risk of complications for a child managed at the DGH was 1.76 (95% confidence interval, 1.44-2.16; P < .0001) and that of readmission was 1.76 (95% confidence interval, 1.43-2.16; P < .0001) when compared with the RU. CONCLUSIONS Patients with appendicitis managed in the DGH had a higher risk of complications and readmission. However, this appears to be related to the use of a care pathway at the RU. Introduction of a care pathway in the DGH may improve outcomes and thus support the ongoing provision of general paediatric surgery.
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Ait Ali Slimane M, Montupet P. [The pediatric surgeon and acute appendicitis]. JOURNAL DE CHIRURGIE 2009; 146 Spec No 1:32-35. [PMID: 19846095 DOI: 10.1016/j.jchir.2009.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
The management of acute appendicitis in the pediatric patient has undergone radical rethinking in recent years. It has been shown that simple uncomplicated acute appendicitis can be successfully managed with antibiotic therapy and may not even require interval appendectomy. Appendicitis complicated by perforation, abscess, or inflammatory phlegmon can be successfully treated by initial antibiotic therapy (with or without percutaneous drainage) and delayed interval appendectomy. While the laparoscopic approach has proved to be well-adapted to many other pediatric surgical procedures, its utility in the treatment of uncomplicated acute appendicitis remains open to debate; compared to standard open appendectomy, it offers only minimal advantages with regard to post-operative care, length of hospital stay, and complications. Children can be managed either by general surgeons or pediatric surgeons depending on the organization of the emergency service; there may be a higher incidence of removal of a normal appendix in non-specialized services.
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Affiliation(s)
- M Ait Ali Slimane
- Clinique chirurgicale de Boulogne-Billancourt, 105, avenue Victor-Hugo, 92100 Boulogne-Billancourt, France.
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Whisker L, Luke D, Hendrickse C, Bowley DM, Lander A. Appendicitis in children: a comparative study between a specialist paediatric centre and a district general hospital. J Pediatr Surg 2009; 44:362-7. [PMID: 19231535 DOI: 10.1016/j.jpedsurg.2008.10.086] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2008] [Accepted: 10/23/2008] [Indexed: 11/19/2022]
Abstract
PURPOSE The study aimed to compare paediatric appendicectomy practice in a specialist paediatric centre (SPC) with a district general hospital (DGH). METHODS This was a retrospective study of children younger than 16 years treated between January 1, 2005, and September 30, 2007. RESULTS Two hundred seven patients (SPC) and 264 (DGH) had an operation for suspected appendicitis. Thirty-one percent of SPC patients were female vs 41% in the DGH (P = .03). Median age (range) was 10.3 years (1.2-15.9 years) in the SPC and 11.8 (3.3-16.0 years) in the DGH (P < or = .0001). The negative appendicectomy rate was 4% at the SPC and 20% at the DGH (P < or = .0001). Perforated appendicitis was found in 37% of children at the SPC compared with only 18% at the DGH (P < or = .0001). Median (range) length of stay was 5 days at the SPC (1-21 days) compared with 2 days at the DGH (1-21 days) (P < or = .0001). CONCLUSION Our findings have important implications for local practice in our 2 centres but may also have wider implications for the national organisation of the surgical care of children and for the training of general surgeons.
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Affiliation(s)
- Lisa Whisker
- Birmingham Children's Hospital NHS Foundation Trust, Steelhouse Lane, Birmingham, UK.
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Tuggle CT, Roman SA, Wang TS, Boudourakis L, Thomas DC, Udelsman R, Ann Sosa J. Pediatric endocrine surgery: who is operating on our children? Surgery 2008; 144:869-77; discussion 877. [PMID: 19040991 DOI: 10.1016/j.surg.2008.08.033] [Citation(s) in RCA: 150] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2008] [Accepted: 08/20/2008] [Indexed: 12/01/2022]
Abstract
BACKGROUND High surgeon volume is associated with improved outcomes in adult endocrine surgery. This is the first population-based outcomes study for thyroidectomy/parathyroidectomy in children. METHODS Cross-sectional analyses were performed using 1999 to 2005 Healthcare Cost and Utilization Project Nationwide Inpatient Sample data. Outcomes included complications, length of stay (LOS), and costs. High-volume surgeons performed >30 cervical endocrine procedures per year in adults and children; pediatric surgeons restricted >90% of their practices to patients </=17 years old. Other surgeons fell into neither category. Bivariate and multivariate regression analyses were performed. RESULTS We included 607 patients, representing 20% of the pediatric endocrine operations done between 1999 and 2005 in the United States. Seventy-six percent of patients were female. Among the procedures performed, 92% were thyroidectomies and 8% were parathyroidectomies. Surgeons were classified as follows: 18% High-volume, 21% Pediatric, and 61% Other. High-volume surgeons had the lowest LOS (1.5 days vs 2.3 Pediatric, 2.0 Other; P = .01), costs ($12,474 vs $19,594 Pediatric, $13,614 Other; P < .01), and complications (6% vs 11% Pediatric, 10% Other; P = NS). In multivariate analyses, case volume of the endocrine surgeons was an independent predictor of LOS and costs. CONCLUSION High-volume surgeons have better outcomes after thyroidectomy/parathyroidectomy in children compared with Pediatric and Other surgeons. Surgeon experience was an independent predictor of LOS and costs. High-volume endocrine and pediatric surgeons could combine expertise to improve outcomes in children.
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Affiliation(s)
- Charles T Tuggle
- Department of Surgery, Yale University School of Medicine, New Haven, Conn, USA
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Peng S, Fancourt M, Gilkison W, Kyle S, Mosquera D. PAEDIATRIC SURGERY CARRIED OUT BY GENERAL SURGEONS: A RURAL NEW ZEALAND EXPERIENCE. ANZ J Surg 2008; 78:662-4. [DOI: 10.1111/j.1445-2197.2008.04612.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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