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Hickner BT, Portuondo JI, Mehl SC, Shah SR, Raval MV, Massarweh NN. Complication Timing, Failure to Rescue, and Readmission After Inpatient Pediatric Surgery. J Surg Res 2024; 302:263-273. [PMID: 39116825 DOI: 10.1016/j.jss.2024.07.052] [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: 08/10/2023] [Revised: 05/15/2024] [Accepted: 07/10/2024] [Indexed: 08/10/2024]
Abstract
BACKGROUND Complications are associated with postoperative mortality and readmission. However, the timing of complications relative to discharge and the extent to which timing is associated with failure to rescue (FTR) and readmission after pediatric surgery is unknown. Our goal was to describe the timing of complications relative to discharge after inpatient pediatric surgery and determine the association between complication timing, FTR, and unplanned readmission. MATERIALS AND METHODS National cohort study of patients within the NSQIP-Pediatric database who underwent inpatient surgery (2012-2019). Complications were categorized based on when they occurred relative to discharge: only pre-discharge, only post-discharge, both. The association between perioperative outcomes and the timing of postoperative complications was evaluated with multivariable hierarchical regression. RESULTS Among 378,551 patients, 30,213 (8.0%) had at least one postoperative complication. Relative to patients with pre-discharge complications, post-discharge complications were associated with significantly decreased odds of FTR (odds ratio 0.21, 95% confidence interval [0.15-0.28]) and significantly increased odds of readmission (odds ratio 19.37 [17.93-20.92]). Odds of FTR and readmission in patients with complications occurring both before and after discharge were similar to that of patients with only post-discharge complications. CONCLUSIONS FTR and readmission are associated with complications occurring at different times relative to discharge (FTR primarily pre-discharge; readmission primarily post-discharge). This suggests a 'one size fits all' approach to surgical quality improvement may not be effective and different approaches are needed to address different quality indicators.
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Affiliation(s)
- Brian T Hickner
- Michael E DeBakey Department of Surgery at Baylor College of Medicine, Houston, Texas.
| | - Jorge I Portuondo
- Michael E DeBakey Department of Surgery at Baylor College of Medicine, Houston, Texas; Center for Innovations in Quality, Effectiveness, and Safety, Michael E DeBakey VA Medical Center, Houston, Texas
| | - Steven C Mehl
- Michael E DeBakey Department of Surgery at Baylor College of Medicine, Houston, Texas; Texas Children's Hospital Department of Surgery, Houston, Texas
| | | | - Mehul V Raval
- Surgical Outcomes and Quality Improvement Center, Center for Healthcare Studies, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Nader N Massarweh
- Surgical and Perioperative Care, Atlanta VA Health Care System, Decatur, Georgia; Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia; Department of Surgery, Morehouse School of Medicine, Atlanta, Georgia
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2
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Terui K, Tachimori H, Oita S, Fujiogi M, Fujishiro J, Hirahara N, Miyata H, Hishiki T. Influence of surgical volume on the mortality and morbidity of gastrointestinal perforation in children. Surg Today 2024; 54:419-427. [PMID: 37615756 DOI: 10.1007/s00595-023-02742-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Accepted: 08/09/2023] [Indexed: 08/25/2023]
Abstract
PURPOSE To clarify the influence of surgical volume on the mortality and morbidity of gastrointestinal perforation in children in Japan. METHODS We collected data on pediatric patients with gastrointestinal perforation between 2017 and 2019, from the National Clinical Database. The surgical volumes of various institutions were classified into three groups: low (average number of surgeries for gastrointestinal perforation/year < 1), medium (≥ 1, < 6), and high (≥ 6). The observed-to-expected (o/e) ratios of 30-day mortality and morbidity were calculated for each group using an existing risk model. RESULTS Among 1641 patients (median age, 0.0 years), the 30-day mortality and morbidity rates were 5.2% and 37.7%, respectively. The 30-day mortality rates in the low-, medium-, and high-volume institutions were 4.9%, 5.3%, and 5.1% (p = 0.94), and the 30-day morbidity rates in the three groups were 26.8%, 39.7%, and 37.7% (p < 0.01), respectively. The o/e ratios of 30-day mortality were 1.05 (95% confidence interval [CI] 0.83-1.26), 1.08 (95% CI 1.01-1.15), and 1.02 (95% CI 0.91-1.13), and those of 30-day morbidity were 1.72 (95% CI 0.93-2.51), 1.03 (95% CI 0.79-1.28), and 0.95 (95% CI 0.56-1.33), respectively. CONCLUSION Surgical volume does not have significant impact on the outcomes of pediatric gastrointestinal perforation in Japan.
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Affiliation(s)
- Keita Terui
- Department of Pediatric Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8677, Japan.
| | - Hisateru Tachimori
- Endowed Course for Health System Innovation, Keio University School of Medicine, Tokyo, Japan
- Department of Healthcare Quality Assessment, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Satoru Oita
- Department of Pediatric Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8677, Japan
| | - Michimasa Fujiogi
- Department of Surgery, National Center for Child Health and Development, Tokyo, Japan
| | - Jun Fujishiro
- Department of Pediatric Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Norimichi Hirahara
- Digital Health and Innovation Unit, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Hiroaki Miyata
- Endowed Course for Health System Innovation, Keio University School of Medicine, Tokyo, Japan
- Department of Health Policy and Management, Keio University, Tokyo, Japan
| | - Tomoro Hishiki
- Department of Pediatric Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8677, Japan
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3
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M S, Jayanthi R, Manne P. Anaesthetic management of a child with Fontan heart undergoing laparoscopic cholecystectomy: A case report. J Perioper Pract 2024; 34:70-74. [PMID: 36867074 DOI: 10.1177/17504589221148025] [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: 03/04/2023]
Abstract
The Fontan procedure is a staged palliative surgery performed in children with congenital univentricular heart defects. These individuals are predisposed to a variety of issues due to their altered physiology. Through this article, we would like to describe the evaluation and anaesthetic management of a 14-year-old boy with Fontan circulation who underwent an uneventful laparoscopic cholecystectomy. The key to successful management was a multidisciplinary approach throughout the perioperative period as these patients pose a unique set of problems.
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Affiliation(s)
- Siddharth M
- Kanchi Kamakoti CHILDS Trust Hospital, Chennai, India
| | - R Jayanthi
- Kanchi Kamakoti CHILDS Trust Hospital, Chennai, India
| | - Prasad Manne
- Kanchi Kamakoti CHILDS Trust Hospital, Chennai, India
- The Royal College of Surgeons of England, London, UK
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4
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Wang H, Luu V, Jiang E, Kirkland O, Kabir S, Davis SS, Hugh TJ. Evaluation of a modified emergency surgical acuity score in predicting operative and non-operative mortality and morbidity in an acute surgical unit. ANZ J Surg 2023; 93:2297-2302. [PMID: 37296520 DOI: 10.1111/ans.18564] [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] [Received: 02/16/2023] [Revised: 05/29/2023] [Accepted: 05/30/2023] [Indexed: 06/12/2023]
Abstract
BACKGROUND Emergency general surgery (EGS) patients have an increased risk of mortality and morbidity compared to other surgical patients. Limited risk assessment tools exist for use in both operative and non-operative EGS patients. We assessed the accuracy of a modified Emergency Surgical Acuity Score (mESAS) in EGS patients at our institution. METHODS A retrospective cohort study from an acute surgical unit at a tertiary referral hospital was performed. Primary endpoints assessed included death before discharge, length of stay (LOS) >5 days and unplanned readmission within 28 days. Operative and non-operative patients were analysed separately. Validation was performed using the area under the receiver operating characteristic (AUROC), Brier score and Hosmer-Lemeshow test. RESULTS A total of 1763 admissions between March 2018 and June 2021 were included for analysis. The mESAS was an accurate predictor of both death before discharge (AUROC 0.979, Brier score 0.007, Hosmer-Lemeshow P = 0.981) and LOS >5 days (0.787, 0.104, and 0.253, respectively). The mESAS was less accurate in predicting readmission within 28 days (0.639, 0.040, and 0.887, respectively). The mESAS retained its predictive ability for death before discharge and LOS >5 days in the split cohort analysis. CONCLUSION This study is the first to validate a modified ESAS in a non-operatively managed EGS population internationally and the first to validate the mESAS in Australia. The mESAS accurately predicts death before discharge and prolonged LOS for all EGS patients, providing a highly useful tool for surgeons and EGS units worldwide.
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Affiliation(s)
- Hogan Wang
- Northern Clinical School, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Veronica Luu
- Data Analysis and Surgical Outcomes Unit, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Eric Jiang
- Surgical Education Research and Training Institute, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Olivia Kirkland
- Acute Surgical Unit, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Shahrir Kabir
- Northern Clinical School, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
- Acute Surgical Unit, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Sean S Davis
- Northern Clinical School, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
- Acute Surgical Unit, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Thomas J Hugh
- Northern Clinical School, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
- Surgical Education Research and Training Institute, Royal North Shore Hospital, Sydney, New South Wales, Australia
- Acute Surgical Unit, Royal North Shore Hospital, Sydney, New South Wales, Australia
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5
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Saito JM, Barnhart DC, Grant C, Brighton BK, Raval MV, Campbell BT, Kenney B, Jatana KR, Ellison JS, Cina RA, Allori AC, Uejima T, Roke D, Lam S, Johnson EK, Goretsky MJ, Byrd C, Iwaniuk M, Nayak R, Thompson VM, Cohen ME, Hall BL, Ko CY, Rangel SJ. The past, present and future of ACS NSQIP-Pediatric: Evolution from a quality registry to a comparative quality performance platform. Semin Pediatr Surg 2023; 32:151275. [PMID: 37075656 DOI: 10.1016/j.sempedsurg.2023.151275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/21/2023]
Abstract
Quality and process improvement (QI/PI) in children's surgical care require reliable data across the care continuum. Since 2012, the American College of Surgeons' (ACS) National Surgical Quality Improvement Program-Pediatric (NSQIP-Pediatric) has supported QI/PI by providing participating hospitals with risk-adjusted, comparative data regarding postoperative outcomes for multiple surgical specialties. To advance this goal over the past decade, iterative changes have been introduced to case inclusion and data collection, analysis and reporting. New datasets for specific procedures, such as appendectomy, spinal fusion for scoliosis, vesicoureteral reflux procedures, and tracheostomy in children less than 2 years old, have incorporated additional risk factors and outcomes to enhance the clinical relevance of data, and resource utilization to consider healthcare value. Recently, process measures for urgent surgical diagnoses and surgical antibiotic prophylaxis variables have been developed to promote timely and appropriate care. While a mature program, NSQIP-Pediatric remains dynamic and responsive to meet the needs of the surgical community. Future directions include introduction of variables and analyses to address patient-centered care and healthcare equity.
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Affiliation(s)
- Jacqueline M Saito
- Division of Pediatric Surgery, Washington University, St. Louis, MO, USA.
| | - Douglas C Barnhart
- Division of Pediatric Surgery, University of Utah, Salt Lake City, UT, USA
| | - Catherine Grant
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL, USA
| | - Brian K Brighton
- Division of Pediatric Orthopedic Surgery, Carolinas Medical Center, Wake Forest School of Medicine, Charlotte, NC, USA
| | - Mehul V Raval
- Division of Pediatric Surgery, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | - Brian Kenney
- Department of Pediatric Surgery, Nationwide Children's Hospital and Ohio State University, Columbus, OH, USA
| | - Kris R Jatana
- Department of Pediatric Otolaryngology, Nationwide Children's Hospital and Ohio State University, Columbus, OH, USA
| | - Jonathan S Ellison
- Division of Pediatric Urology, Department of Urology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Robert A Cina
- Division of Pediatric Surgery, Department of Surgery, Shawn Jenkins Children's Hospital, The Medical University of South Carolina, Charleston, SC, USA
| | - Alexander C Allori
- Division of Plastic, Maxillofacial and Oral Surgery, Department of Surgery and Department of Population Health Sciences, Duke University, Durham, NC, USA
| | - Tetsu Uejima
- Department of Pediatric Anesthesiology and Perioperative Medicine, Nemours Children's Hospital Delaware, Thomas Jefferson University, Philadelphia, USA
| | - Daniel Roke
- Department of Anesthesia & Critical Care Medicine, St. Louis University, St. Louis, MO, USA
| | - Sandi Lam
- Division of Pediatric Neurosurgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Emilie K Johnson
- Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Michael J Goretsky
- Division of Pediatric Surgery, Children's Hospital of the King's Daughters, Eastern Virginia Medical School, Norfolk, VA, USA
| | - Claudia Byrd
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL, USA
| | - Marie Iwaniuk
- Independent Statistical Consultant, Phoenixville, PA, USA
| | - Raageswari Nayak
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL, USA
| | - Vanessa M Thompson
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL, USA
| | - Mark E Cohen
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL, USA
| | - Bruce L Hall
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL, USA; Department of Surgery, Washington University St. Louis School of Medicine and BJC Healthcare, St. Louis, MO, USA
| | - Clifford Y Ko
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL, USA
| | - Shawn J Rangel
- Department of Surgery, Boston Children's Hospital, Boston, MA, USA
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6
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Brown SES, Hall M, Cassidy RB, Zhao X, Kheterpal S, Feudtner C. Tracheostomy, Feeding-Tube, and In-Hospital Postoperative Mortality in Children: A Retrospective Cohort Study. Anesth Analg 2023; 136:1133-1142. [PMID: 37014983 DOI: 10.1213/ane.0000000000006413] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2023]
Abstract
BACKGROUND Neuromuscular/neurologic disease confers increased risk of perioperative mortality in children. Some patients require tracheostomy and/or feeding tubes to ameliorate upper airway obstruction or respiratory failure and reduce aspiration risk. Empiric differences between patients with and without these devices and their association with postoperative mortality have not been previously assessed. METHODS This retrospective cohort study using the Pediatric Health Information System measured 3- and 30-day in-hospital postsurgical mortality among children 1 month to 18 years of age with neuromuscular/neurologic disease at 44 US children's hospitals, from April 2016 to October 2018. We summarized differences between patients presenting for surgery with and without these devices using standardized differences. Then, we calculated 3- and 30-day mortality among patients with tracheostomy, feeding tube, both, and neither device, overall and stratified by important exposures, using Fisher exact test to test whether differences were significant. RESULTS There were 43,193 eligible patients. Unadjusted 3-day mortality was 1.3% (549/43,193); 30-day mortality was 2.7% (1168/43,193). Most (79.1%) used neither a feeding tube or tracheostomy, 1.2% had tracheostomy only, 15.5% had feeding tube only, and 4.2% used both devices. Compared to children with neither device, children using either or both devices were more likely to have multiple CCCs, dysphagia, chronic pulmonary disease, cerebral palsy, obstructive sleep apnea, or malnutrition, and a prolonged intensive care unit (ICU) stay within the previous year. They were less likely to present for high-risk surgeries (33% vs 57%). Having a feeding tube was associated with decreased 3-day mortality overall compared to having neither device (0.9% vs 1.3%, P = .003), and among children having low-risk surgery, and surgery during urgent or emergent hospitalizations. Having both devices was associated with decreased 3-day mortality among children having low-risk surgery (0.8% vs 1.9%; P = .013), and during urgent or emergent hospitalizations (1.6% vs 2.9%; P = .023). For 30-day mortality, having a feeding tube or both devices was associated with lower mortality when the data were stratified by the number of CCCs. CONCLUSIONS Patients requiring tracheostomy, feeding tube, or both are generally sicker than patients without these devices. Despite this, having a feeding tube was associated with lower 3-day mortality overall and lower 30-day mortality when the data were stratified by the number of CCCs. Having both devices was associated with lower 3-day mortality in patients presenting for low-risk surgery, and surgery during urgent or emergent hospitalizations.
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Affiliation(s)
- Sydney E S Brown
- From the Department of Anesthesiology, The University of Michigan, Ann Arbor, Michigan
| | - Matt Hall
- Children's Hospital Association, Lenexa, Kansas
| | - Ruth B Cassidy
- From the Department of Anesthesiology, The University of Michigan, Ann Arbor, Michigan
| | - Xinyi Zhao
- From the Department of Anesthesiology, The University of Michigan, Ann Arbor, Michigan
| | - Sachin Kheterpal
- From the Department of Anesthesiology, The University of Michigan, Ann Arbor, Michigan
| | - Chris Feudtner
- The Pediatric Advanced Care Team, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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7
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Valencia E, Staffa SJ, Aslam Y, Faraoni D, DiNardo JA, Rangel SJ, Nasr VG. Validation of Automated Data Extraction From the Electronic Medical Record to Provide a Pediatric Risk Assessment Score. Anesth Analg 2023; 136:738-744. [PMID: 36763524 DOI: 10.1213/ane.0000000000006300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
BACKGROUND Although the rate of pediatric postoperative mortality is low, the development and validation of perioperative risk assessment models have allowed for the stratification of those at highest risk, including the Pediatric Risk Assessment (PRAm) score. The clinical application of such tools requires manual data entry, which may be inaccurate or incomplete, compromise efficiency, and increase physicians' clerical obligations. We aimed to create an electronically derived, automated PRAm score and to evaluate its agreement with the original American College of Surgery National Surgical Quality Improvement Program (ACS NSQIP)-derived and validated score. METHODS We performed a retrospective observational study of children <18 years who underwent noncardiac surgery from 2017 through 2021 at Boston Children's Hospital (BCH). An automated PRAm score was developed via electronic derivation of International Classification of Disease (ICD) -9 and -10 codes. The primary outcome was agreement and correlation among PRAm scores obtained via automation, NSQIP data, and manual physician entry from the same BCH cohort. The secondary outcome was discriminatory ability of the 3 PRAm versions. Fleiss Kappa, Spearman correlation (rho), and intraclass correlation coefficient (ICC) and receiver operating characteristic (ROC) curve analyses with area under the curve (AUC) were applied accordingly. RESULTS Of the 6014 patients with NSQIP and automated PRAm scores (manual scores: n = 5267), the rate of 30-day mortality was 0.18% (n = 11). Agreement and correlation were greater between the NSQIP and automated scores (rho = 0.78; 95% confidence interval [CI], 0.76-0.79; P <.001; ICC = 0.80; 95% CI, 0.79-0.81; Fleiss kappa = 0.66; 95% CI, 0.65-0.67) versus the NSQIP and manual scores (rho = 0.73; 95% CI, 0.71-0.74; P < .001; ICC = 0.78; 95% CI, 0.77-0.79; Fleiss kappa = 0.56; 95% CI, 0.54-0.57). ROC analysis with AUC showed the manual score to have the greatest discrimination (AUC = 0.976; 95% CI, 0.959,0.993) compared to the NSQIP (AUC = 0.904; 95% CI, 0.792-0.999) and automated (AUC = 0.880; 95% CI, 0.769-0.999) scores. CONCLUSIONS Development of an electronically derived, automated PRAm score that maintains good discrimination for 30-day mortality in neonates, infants, and children after noncardiac surgery is feasible. The automated PRAm score may reduce the preoperative clerical workload and provide an efficient and accurate means by which to risk stratify neonatal and pediatric surgical patients with the goal of improving clinical outcomes and resource utilization.
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Affiliation(s)
| | - Steven J Staffa
- Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Yousuf Aslam
- Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - David Faraoni
- Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - James A DiNardo
- Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Shawn J Rangel
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Viviane G Nasr
- Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
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8
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Tram NK, Mpody C, Owusu-Bediako K, Murillo-Deluquez ME, Tobias JD, Nafiu OO. Childhood obesity trends: Association with same-day hospital admission in a National Outpatient Surgical Population. Paediatr Anaesth 2023; 33:312-318. [PMID: 36527422 DOI: 10.1111/pan.14617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 11/30/2022] [Accepted: 12/13/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Although the prevalence of obesity in the general population and its perioperative implications among children undergoing inpatient surgeries are well known, little is known about obesity prevalence among children scheduled for ambulatory surgery. AIMS Here, we report the trends of obesity and severe obesity among children who underwent ambulatory surgery across multiple centers in the United States and explore the association of obesity status with admission following elective ambulatory surgery. MATERIALS AND METHODS Using data from the American College of Surgeons National Surgical Quality Improvement Program-Pediatric (2012-2019), we selected children 2-18 years old who underwent outpatient surgical procedures under general anesthesia and had documented height, weight, and body mass index (BMI) data. We estimated the prevalence of overweight, obesity (class 1), and severe obesity (class 2 and class 3) patients and explored their association with same-day hospital admission, defined as hospital length of stay ≥1 day. RESULTS Data from 152 918 children (mean age: 9.7 ± 4.7 years) were analyzed. Of these, 16.4% (n = 25 007) were overweight, 13.8% (n = 21 085) were class 1 obese, 5.2% (n = 7879) were class 2 obese, and 3.0% (n = 4623) were class 3 obese. From 2012 to 2019, class 2 or 3 obesity prevalence increased by 26.7% and 32.5%, respectively. Overweight and obese children had relatively higher odds of same-day hospital admission compared to healthy weight children (overweight odds ratio [95% confidence interval]: 1.05 [1.02, 1.08]; class 1 obesity: 1.04 [1.00, 1.07]; class 2 obesity: 1.09 [1.02, 1.16]; class 3 obesity: 1.20 [1.11, 1.30]). DISCUSION AND CONCLUSION The burden of obesity continues to increase in children scheduled for ambulatory surgery. Children with class 2 and class 3 obesity have higher rates of same-day hospital admission following elective ambulatory surgery compared to healthy weight children, a factor that should be considered in scheduling these patients.
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Affiliation(s)
- Nguyen K Tram
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA.,Department of Anesthesiology & Pain Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Christian Mpody
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA.,Department of Anesthesiology & Pain Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Kwaku Owusu-Bediako
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA
| | | | - Joseph D Tobias
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA.,Department of Anesthesiology & Pain Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Olubukola O Nafiu
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA.,Department of Anesthesiology & Pain Medicine, The Ohio State University, Columbus, Ohio, USA
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9
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Bertsimas D, Li M, Zhang N, Estrada C, Scott Wang HH. High-performance pediatric surgical risk calculator: A novel algorithm based on machine learning and pediatric NSQIP data. Am J Surg 2023:S0002-9610(23)00106-X. [PMID: 36948897 DOI: 10.1016/j.amjsurg.2023.03.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 02/09/2023] [Accepted: 03/10/2023] [Indexed: 03/14/2023]
Abstract
BACKGROUNDS New methods such as machine learning could provide accurate predictions with little statistical assumptions. We seek to develop prediction model of pediatric surgical complications based on pediatric National Surgical Quality Improvement Program(NSQIP). METHODS All 2012-2018 pediatric-NSQIP procedures were reviewed. Primary outcome was defined as 30-day post-operative morbidity/mortality. Morbidity was further classified as any, major and minor. Models were developed using 2012-2017 data. 2018 data was used as independent performance evaluation. RESULTS 431,148 patients were included in the 2012-2017 training and 108,604 were included in the 2018 testing set. Our prediction models had high performance in mortality prediction at 0.94 AUC in testing set. Our models outperformed ACS-NSQIP Calculator in all categories for morbidity (0.90 AUC for major, 0.86 AUC for any, 0.69 AUC in minor complications). CONCLUSIONS We developed a high-performing pediatric surgical risk prediction model. This powerful tool could potentially be used to improve the surgical care quality.
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Affiliation(s)
- Dimitris Bertsimas
- Operations Research Center, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Michael Li
- Operations Research Center, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Nova Zhang
- Operations Research Center, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Carlos Estrada
- Advanced Analytics Group of Pediatric Urology, Department of Urology, Boston Children's Hospital, Boston, MA, USA
| | - Hsin-Hsiao Scott Wang
- Advanced Analytics Group of Pediatric Urology, Department of Urology, Boston Children's Hospital, Boston, MA, USA.
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10
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Improving Surgical Research Capacity in Low- and Middle-Income Countries: Can Episodic Data Collection Reliably Estimate Perioperative Mortality? Ann Surg 2023; 277:e714-e718. [PMID: 34334654 DOI: 10.1097/sla.0000000000005105] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The aim of this study was to empirically determine the optimal sample size needed to reliably estimate perioperative mortality (POMR) in different contexts. SUMMARY BACKGROUND DATA POMR is a key metric for measuring the quality and safety of surgical systems and will need to be tracked as surgical care is scaled up globally. Continuous collection of outcomes for all surgical cases is not the standard in high-income countries and may not be necessary in low- and middle-income countries. METHODS We created simulated datasets to determine the sampling frame needed to reach a given precision. We validated our findings using data collected at Mulago National Referral Hospital in Kampala, Uganda. We used these data to create a tool that can be used to determine the optimal sampling frame for a population based on POMR rate and target POMR improvement goal. RESULTS Precision improved as the sampling frame increased. However, as POMR increased, lower sampling percentages were needed to achieve a given precision. A total of 357 eligible cases were identified in the Mulago database with an overall POMR rate of 14%. Precision of ±10% was achieved with 34% sampling, and precision of ±25% was obtained at 9% sampling. Using simulated datasets, a tool was created to determine the minimum sample percentage needed to detect a given mortality improvement goal. CONCLUSIONS Reliably tracking POMR does not require continuous data collection. Data driven sampling strategies can be used to decrease the burden of data collection to track POMR in resource-constrained settings.
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Cook BH, Choi PM, Lucas DJ. Surgical outcomes in children with Trisomy 13: An ACS NSQIP - Pediatric review. J Pediatr Surg 2023; 58:384-388. [PMID: 36008197 DOI: 10.1016/j.jpedsurg.2022.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 07/22/2022] [Accepted: 08/11/2022] [Indexed: 10/15/2022]
Abstract
BACKGROUND Trisomy 13 is a rare genetic condition with a characteristic set of severe congenital abnormalities. Traditionally, the standard of care was to provide palliative care only. However, there has been a recent shift towards life-prolonging care, including surgery. This study seeks to describe surgical outcomes in patients with trisomy 13 and compare them to comorbidity-matched controls. METHODS Using the ACS NSQIP Pediatric 2012-2019 Participant Use Data Files, patients with trisomy 13 were identified and described. A nearest-neighbor 10:1 propensity score match was performed using demographics, comorbidities, and procedural details. This yielded 254 patients with trisomy 13 and 2,422 controls. Risk ratios for morbidity and mortality by trisomy 13 status were determined using modified Poisson regression. The primary outcomes were thirty-day mortality and the occurrence of any morbidity. RESULTS The median age of patients with trisomy 13 was 16 months (IQR 87 months). 126 were male (49.6%) and 128 were female (50.4%). There were no differences in overall morbidity compared to controls (31.8% vs. 29.7%, RR 1.06, 95%CI 0.87-1.28, p = 0.554), but patients with trisomy 13 had markedly higher mortality (7.9% vs. 1.8%, RR 4.43, 95%CI 2.28-8.61, p<0.001). CONCLUSIONS We conclude that patients with trisomy 13 undergoing surgery have frequent morbidity and an elevated although not prohibitive risk of death. Compared to patients with similar comorbidities, they have similar rates of morbidity but a markedly higher risk of mortality. Parents of children with trisomy 13 require thorough counseling on these risks before deciding on surgery.
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Affiliation(s)
- Brittany H Cook
- F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, USA
| | - Pamela M Choi
- F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, USA; Division of Pediatric Surgery, Department of General Surgery, Naval Medical Center San Diego, 34800 Bob Wilson Drive, San Diego, California 92134, United States of America
| | - Donald J Lucas
- F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, USA; Division of Pediatric Surgery, Department of General Surgery, Naval Medical Center San Diego, 34800 Bob Wilson Drive, San Diego, California 92134, United States of America.
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12
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Mistry M, Boyle L, Taylor E, Campbell D. Development and validation of a national perioperative mortality risk model for pediatric surgery: The New Zealand pediatric surgical risk tool (NZRISK-pediatric): NZRISK-Pediatric. J Pediatr Surg 2023; 58:524-531. [PMID: 35970677 DOI: 10.1016/j.jpedsurg.2022.07.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Revised: 07/04/2022] [Accepted: 07/18/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Risk prediction models are well established as an adjunct to perioperative decision making, but few exist for pediatric surgical outcomes. The majority of risk tools do not feature Australasian data and do not estimate mortality risk beyond 30-days. Our aim was to develop and validate a model for mortality risk prediction in children (age <18yrs) at 30-days, 90-days and 1 year following all types of surgery using a national database. METHODS AND RESULTS The New Zealand Ministry of Health National Minimum Dataset was accessed to obtain clinical and demographic data for all children having surgery between June 1st 2011 and July 1st 2016. Three quarters of the data were used to derive 3 models to predict 30-day, 90-day and 1-year mortality risk, and the remaining data used for validation. We constructed 3 models using data from 135 217 patients, validating a total of 11 covariates for risk prediction. Included were neonate, prematurity, ASA-PS status, heart and lung disease, active malignancy, sepsis, surgical type, surgical severity score, surgical urgency, ethnicity and socioeconomic deprivation. All models showed excellent discrimination (area under the receiver operating characteristic curve (AUROC) values of 0.947, 0.933 and 0.908 respectively) and calibration statistics (calibration slopes of 0.778, 1.125, 1.153, Brier scores of 0.001, 0.002, 0.003 respectively). CONCLUSION Combining objective data with severity indices, NZRISK-Paed presents a risk stratification model which is intuitive and practical. Application of 30-day, 90-day and 1-year percentage mortality risk aids in longer-term planning, shared decision-making and allocation of resource to the individual and to high needs populations. Risk prediction tools add an objective measure to pre-operative assessment but few exist for pediatric surgery and none predict mortality beyond 30-days.
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Affiliation(s)
- Manisha Mistry
- Pediatric Anesthesia Fellow, Starship Children's Health, 2 Park Road, Grafton, Auckland 1023, New Zealand.
| | - Luke Boyle
- PhD Candidate, Department of Statistics, The University of Auckland, Auckland 1023, New Zealand
| | - Elsa Taylor
- Specialist Pediatric Anesthetist, Department of Pediatric Anesthesia, Starship Children's Health, 2 Park Rd, Grafton, Auckland 1023, New zealand
| | - Douglas Campbell
- Specialist Anesthetist, Department of Anesthesia and Perioperative Medicine, Auckland City Hospital, 2 Park Road, Grafton, Auckland 1023, New Zealand
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Owusu-Bediako K, Mpody C, Iobst C, Tobias JD, Nafiu OO. Risk assessment of postoperative pneumonia in children with neurologic disorders and obesity. Paediatr Anaesth 2023; 33:160-166. [PMID: 36399010 DOI: 10.1111/pan.14593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 10/26/2022] [Accepted: 10/29/2022] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Postoperative pneumonia increases the risk of postsurgical mortality, making it a serious healthcare-associated complication. Children with preoperative neuromuscular impairments have a higher risk of postoperative pneumonia. Obesity is also a risk factor for postoperative pulmonary complications, including pneumonia. Moreover, obesity is increasingly prevalent among children living with a neurological diagnosis. Whether obesity increases the risk of postoperative pneumonia among children with neurologic diseases remains largely unknown. Therefore, we assessed the risk of postoperative pneumonia among children with neurologic diagnoses based on their obesity status. METHODS We analyzed a retrospective cohort of children ≤18 years from the National Surgical Quality Improvement Program (2012-2019) database who underwent inpatient orthopedic surgery. We used Cox proportional regression model to estimate the hazard ratio for the association between neurologic disorders and postoperative pneumonia. In addition, we included an interaction term between body mass index and neurologic disorders to evaluate the moderating effect of obesity status and then performed stratified analyses to compare the magnitude of hazard ratios across body mass index subgroups. RESULTS A total of 60 745 children underwent inpatient orthopedic surgery during the study period, of whom 43.6% were healthy weight and 30.8% overweight/obese. The median age was 13 years (Interquartile range: 8-15). The incidence of postoperative pneumonia was higher among healthy weight patients with neurologic disorders than healthy weight patients without any neurologic disorders [Hazard ratio: 3.55 vs. 0.34]. Furthermore, the association between neurologic disorders and postoperative pneumonia was strongest among overweight patients than healthy weight or obese patients [Hazard ratio:11.88 vs. 9.45 vs. 4.40]. This observation was consistent across the various neurologic disorders analyzed. CONCLUSION Childhood obesity buffered the association between neurologic disorders and postoperative pneumonia, consistent with an 'obesity paradox'. Further research exploring the underlying mechanisms for the obesity paradox in children with neurologic disorders is warranted.
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Affiliation(s)
- Kwaku Owusu-Bediako
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Christian Mpody
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA.,Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Christopher Iobst
- Department of Pediatric Orthopedic Surgery, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Joseph D Tobias
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA.,Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Olubukola O Nafiu
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA.,Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, Ohio, USA
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Jackson JE, Rajasekar G, Vukcevich O, Coakley BA, Nuño M, Saadai P. Association Between Race, Gender, and Pediatric Postoperative Outcomes: An Updated Retrospective Review. J Surg Res 2023; 281:112-121. [PMID: 36155268 DOI: 10.1016/j.jss.2022.08.027] [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: 11/18/2021] [Revised: 08/05/2022] [Accepted: 08/19/2022] [Indexed: 01/31/2023]
Abstract
INTRODUCTION There has not been a recent evaluation of the association between racial and gender and surgical outcomes in children. We aimed to evaluate improvements in race- and gender-related pediatric postoperative outcomes since a report utilizing the Kids' Inpatient Database data from 2003 to 2006. METHODS Using Kids' Inpatient Database (2009, 2012, 2016), we identified 245,976 pediatric patients who underwent appendectomy for acute appendicitis (93.6%), pyloromyotomy for pyloric stenosis (2.7%), empyema decortication (1.6%), congenital diaphragmatic hernia repair (0.7%), small bowel resection for intussusception (0.5%), or colonic resection for Hirschsprung disease (0.2%). The primary outcome was the development of postoperative complications. Multivariable logistic regression was used to evaluate risk-adjusted associations among race, gender, income, and postoperative complications. RESULTS Most patients were male (61.5%) and 45.7% were White. Postoperative complications were significantly associated with male gender (P < 0.0001) and race (P < 0.0001). After adjustment, Black patients were more likely to experience any complication than White patients (adjusted odds ratio 1.3, confidence interval 1.2-1.4), and males were more likely than females (adjusted odds ratio 1.3, confidence interval 1.2-1.4). CONCLUSIONS No clear progress has been made in eliminating race- or gender-based disparities in pediatric postoperative outcomes. New strategies are needed to better understand and address these disparities.
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Affiliation(s)
- Jordan E Jackson
- Department of Pediatric Surgery, University of California, Davis Medical Center, Sacramento, California
| | - Ganesh Rajasekar
- Department of Public Health Sciences, Division of Biostatistics, University of California Davis, Sacramento, California
| | - Olivia Vukcevich
- Department of Pediatric Surgery, University of California, Davis Medical Center, Sacramento, California
| | - Brian A Coakley
- Division of Pediatric Surgery, Department of Surgery, The Icahn School of Medicine at Mount Sinai, New York, New York
| | - Miriam Nuño
- Department of Public Health Sciences, Division of Biostatistics, University of California Davis, Sacramento, California
| | - Payam Saadai
- Department of Pediatric Surgery, University of California, Davis Medical Center, Sacramento, California.
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Sanford EL, Nair R, Alder A, Sessler DI, Flores G, Szmuk P. Racial/ethnic differences in receipt of surgery among children in the United States. J Pediatr Surg 2022; 57:852-859. [PMID: 35568523 DOI: 10.1016/j.jpedsurg.2022.03.035] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 03/07/2022] [Accepted: 03/31/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND It is unknown whether racial/ethnic disparities exist in surgical utilization for children. The aim, therefore, was to evaluate the odds of surgery among children in the US by race/ethnicity to test the hypothesis that minority children have less surgery. METHODS Cross-sectional data were analyzed on children 0-18 years old from the 1999 to 2018 National Health Interview Survey, a large, nationally representative survey. The primary outcome was odds of surgery in the prior 12 months for non Latino African-American, Asian, and Latino children, compared with non Latino White children, after adjustment for relevant covariates. The National Surgical Quality Improvement Program Pediatric Dataset was used to analyze the odds of emergent/urgent surgery by race/ethnicity. RESULTS Data for 219,098 children were analyzed, of whom 10,644 (4.9%) received surgery. After adjustment for relevant covariates, African-American (AOR, 0.54; 95% CI, 0.50-0.59), Asian (AOR, 0.39; 95% CI, 0.33-0.46), and Latino (AOR, 0.62; 95% CI, 0.57-0.67) children had lower odds of surgery than White children. Latino children were more likely to require emergent or urgent surgery (AOR, 1.71; 95% CI, 1.68-1.74). CONCLUSIONS Latino, African-American, and Asian children have significantly lower adjusted odds of having surgery than White children in America, and Latino children were more likely to have emergent or urgent surgery. These racial/ethnic differences in surgery may reflect disparities in healthcare access which should be addressed through further research, ongoing monitoring, targeted interventions, and quality-improvement efforts. LEVEL OF EVIDENCE II. TYPE OF STUDY Prognosis study.
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Affiliation(s)
- Ethan L Sanford
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Children's Medical Center, Dallas, TX, USA; Department of Pediatric Critical Care, University of Texas Southwestern Medical Center, Children's Medical Center, Dallas, Texas, USA; Outcomes Research Consortium, Cleveland, OH, USA.
| | - Rasmi Nair
- Department of Population and Data Sciences, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Adam Alder
- Department of Pediatric Surgery, University of Texas Southwestern Medical Center, Children's Medical Center, Dallas, TX, USA
| | - Daniel I Sessler
- Outcomes Research Consortium, Cleveland, OH, USA; Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Glenn Flores
- Department of Pediatrics, University of Miami Miller School of Medicine, Miami, FL, USA; Holtz Children's Hospital, Jackson Health System, Miami, FL, USA
| | - Peter Szmuk
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Children's Medical Center, Dallas, TX, USA; Outcomes Research Consortium, Cleveland, OH, USA
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Muacevic A, Adler JR, Shah A, Falgons C, Quan T, Malyavko A, Tabaie S. Association of Race With Post-operative Complications After Spinal Fusion in Children With Cerebral Palsy. Cureus 2022; 14:e32920. [PMID: 36578858 PMCID: PMC9790147 DOI: 10.7759/cureus.32920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/24/2022] [Indexed: 12/26/2022] Open
Abstract
INTRODUCTION Neuromuscular scoliosis in children with cerebral palsy (CP) can lead to debilitating difficulties with pain, ambulation, sitting, and respiratory or cardiac compromise. Spinal fusion can halt deformity progression, though the decision to undergo surgery involves an individualized risk-benefit assessment. The purpose of this study was to evaluate whether race is a risk factor for patients with CP to experience post-operative complications after spinal fusion. METHODS This is a retrospective cohort analysis of a national database. Analyses methods include univariate analyses, multivariate regression models, and other ad-hoc tests. RESULTS There were 3,081 pediatric patients with CP who underwent spinal fusion. Black patients had an increased risk of experiencing any post-operative complication compared to Caucasians (OR 1.322, 95% CI 1.099-1.590). Both Caucasian(p=0.005) and Black (p<0.001) races were risk factors for experiencing medical complications; Black patients had an increased risk compared to Caucasians (OR 1.373, 95% CI 1.130-1.667). Other races had a greater length of ICU stay than Caucasians (median {Mdn}=3.00 days vs Mdn=2.00, p=0.029), and longer total hospital stays than Caucasian and Black patients (Mdn=9.00 days vs Mdn=6.00 days vs Mdn=6.00 days, p<0.001). CONCLUSION Race is an independent risk factor for pediatric patients with CP to experience medical complications following spinal fusion surgery, with Black patients having an increased risk compared to Caucasians. Further, other races were found to have significantly longer ICU and total hospital length of stay. This study is the first to present race as a risk factor for children with CP to experience increased post-operative complications following spinal fusion and will be valuable in understanding their individualized peri-operative courses and risks.
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Bahraini A, Purcell LN, Cole K, Koonce R, Richardson L, Trembath A, deJong N, Sutton A, Hayes AA, Phillips MR. Failure to thrive, oral intake, and inpatient status prior to gastrostomy tube placement in the first year of life is associated with persistent use 1-year later. J Pediatr Surg 2022; 57:723-727. [PMID: 35400490 DOI: 10.1016/j.jpedsurg.2022.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 02/28/2022] [Accepted: 03/01/2022] [Indexed: 11/20/2022]
Abstract
BACKGROUND Gastrostomy tube (GT) placement is a common procedure in infants (≤1-year-old). There is variation in patient selection and a paucity of studies examining which patients require long term enteral access. The objective of this study was to assess demographic and clinical factors associated with persistent GT use (PGU) at 1-year after placement. METHODS We performed a single-institution retrospective review of patients ≤1-year-old who underwent GT placement from January 31, 2014, and January 31, 2020, using institutional NSQIP-P data supplemented with chart review. Multivariable logistic regression analysis was performed to identify factors associated with PGU. Clinical predictors were selected a priori, and a p-value less than 0.05 was used to detect a significant association. RESULTS 140 patients were included, and 118 had a 1-year follow-up. At 1-year following GT placement, 38 patients had weaned from their GT (32.2%). Failure to thrive (FTT), and inpatient admission prior to surgery are associated with increased odds of PGU at 1-year after surgery, OR: 5.19 and 6.02, respectively. There is an inverse association between the percentage of feeds taken by mouth at the time of surgery and the odds of PGU at 1-year (OR: 0.03). CONCLUSION Patients who have FTT (documented prior to surgery) or an inpatient admission prior to GT had a higher odds of PGU at 1-year post-op. Additionally, the amount taken by mouth at the time of GT placement was inversely related to PGU. These factors are important in determining the need for a surgical gastrostomy tube. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Anoosh Bahraini
- Department of Pediatric Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC 27514, USA
| | - Laura N Purcell
- Department of Pediatric Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC 27514, USA
| | - Kristen Cole
- Department of Pediatric Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC 27514, USA
| | - Robin Koonce
- Department of Pediatric Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC 27514, USA
| | - Lisa Richardson
- Department of Pediatric Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC 27514, USA
| | - Andrea Trembath
- Department of Pediatric Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC 27514, USA
| | - Neal deJong
- Department of Pediatric Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC 27514, USA
| | - Ashley Sutton
- Department of Pediatric Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC 27514, USA
| | - Andrea A Hayes
- Department of Pediatric Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC 27514, USA
| | - Michael R Phillips
- Department of Pediatric Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC 27514, USA.
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Perioperative mortality in pediatric patients: a systematic review of risk assessment tools for use in the preoperative setting. Anesthesiology 2022; 137:555-567. [PMID: 36069894 DOI: 10.1097/aln.0000000000004369] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND There are multiple preoperative risk scores for pediatric mortality. The aim of this study was to systematically describe and compare the existing studies of patient-specific multispecialty risk prediction scores for perioperative mortality in pediatric populations, with the goal of guiding clinicians on which may be most appropriate for use in the preoperative setting. METHODS We conducted a systematic literature review of published journal articles that presented the development, extension/updating, and/or validation of a risk score which predicted all-cause mortality (up to 30 days postoperatively) in pediatric patients undergoing a procedure in which anesthesia was used. Scores needed to be applicable to surgeries in more than one non-cardiac surgical specialty and had to be able to be calculated by the anesthesiologist at the time of the pre-anesthetic assessment. Two investigators independently screened studies for inclusion and assessed study quality in the domains of clinical applicability, feasibility/ease of use in the clinical setting, and risk of bias. RESULTS A total of 1,681 titles were retrieved. Of these, 10 studies met inclusion criteria: nine reported the development and validation of scores, and one was an external validation of an existing score. Seven studies used varying years of multicenter data from the National Surgical Quality Improvement Program - Pediatric Participant Use File for development and/or validation. The unadjusted rate of mortality in the studies ranged from 0.3% to 3.6%. The preoperative predictors of mortality used in score development included patient demographics, preoperative therapies, and chronic conditions, among others. All models showed good discrimination upon validation (AUC > 0.8). Most risk scores had high or unclear risks of bias. CONCLUSION There are numerous scores available for the prediction of mortality in pediatric populations, all of which exhibited good performance. However, many have high or unclear risks of bias, and most have not undergone external validation.
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Hamade S, Alshiek J, Javadian P, Ahmed S, McLeod FN, Shobeiri SA. Evaluation of the American College of Surgeons National Surgical Quality Improvement Program Risk Calculator to predict outcomes after hysterectomies. Int J Gynaecol Obstet 2022; 158:714-721. [PMID: 34929052 DOI: 10.1002/ijgo.14075] [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] [Received: 10/08/2021] [Revised: 12/08/2021] [Accepted: 12/17/2021] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To evaluate the American College of Surgeons (ACS) surgical risk calculator's reliability in predicting outcomes in hysterectomies. METHODS This is a prospective cohort study at a large community-based hospital. Twenty-one preoperative and postoperative criteria were abstracted from the electronic medical record and entered into the online ACS calculator to determine a risk score. Logistical regression was used to determine the association between risk score and actual outcome. The prediction capability was analyzed with c-statistic, Hosmer-Lemeshow, and Brier score. RESULTS A total of 634 hysterectomies were performed during the study period from January to April 2019. Patients were predominantly 55 years old, white (53%) and overweight (body mass index 30). Predicted perioperative adverse events were significantly higher than actual adverse events across all domains. In all, 54/634 (8.5%) patients experienced postoperative urinary tract infection. C-statistics for return to operating room, renal failure, and readmission were 0.607 (95% C Statistic index [CI] 0.370-0.845), 0.882 (95% CI 0.802-0.962), 0.637 (95% CI 0.524-0.750), respectively. Brier scores approached one in all categorical domains. CONCLUSION The ACS surgical risk calculator holds the promise of predicting postoperative complications or length of stay for patients undergoing hysterectomy. Further adjustment to this tool is required before it can be advocated for use in the clinical setting.
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Affiliation(s)
- Sara Hamade
- Department of Obstetrics and Gynecology, Inova Fairfax Hospital, Falls Church, Virginia, USA
| | - Jonia Alshiek
- Department of Obstetrics and Gynecology, Inova Fairfax Hospital, Falls Church, Virginia, USA
- Technion Medical School, Hillel Yafe Medical Center, Hadera, Israel
| | - Pouya Javadian
- Department of Obstetrics and Gynecology, Inova Fairfax Hospital, Falls Church, Virginia, USA
| | - Sushma Ahmed
- Department of Obstetrics and Gynecology, Inova Fairfax Hospital, Falls Church, Virginia, USA
| | - Francine N McLeod
- Department of Obstetrics and Gynecology, Inova Fairfax Hospital, Falls Church, Virginia, USA
| | - S Abbas Shobeiri
- Department of Obstetrics and Gynecology, Inova Fairfax Hospital, Falls Church, Virginia, USA
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Portuondo JI, Mehl SC, Shah SR, Raval MV, Zhu H, Fallon SC, Wesson DE, Massarweh NN. Association between index complication and outcomes after inpatient pediatric surgery. J Pediatr Surg 2022; 57:1-8. [PMID: 35422334 DOI: 10.1016/j.jpedsurg.2022.03.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 02/25/2022] [Accepted: 03/17/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE A cascade of complications is believed to be the primary mechanism underlying failure to rescue (FTR), or death of a patient after a postoperative complication. It is unknown whether specific types of index complications are associated with the incidence of secondary complications and FTR after pediatric surgery. METHODS National cohort study of patients within the National Surgical Quality Improvement Program-Pediatric database who underwent inpatient surgery (2012-2019). Index complications were grouped into nine categories (cardiovascular, venous thromboembolism, pulmonary, bleeding/transfusion, renal, central nervous system, wound, infectious, or minor [defined as having an associated mortality rate <1%]). The association between the type of index complication with FTR, secondary complications, reoperation, unplanned readmission, and postoperative length of stay was evaluated with multivariable logistic regression and generalized linear modeling. RESULTS Among 425,386 patients, 15.5% had at least one complication, 16.6% had one or more secondary complications, 13.9% reoperation, 14.5% readmission, and 2.4% FTR. Secondary complication (10.8-59.7%) and FTR (0.3-31.1%) rates varied by type of index complication. Relative to patients who had an index minor complication, those with an index infectious complication were most likely to have secondary complication (Odds Ratio [OR] 10.3, 95% CI [9.36-11.4]). Index CV complications were most strongly associated with FTR (OR 30.7 [24.0-39.4]). Index wound complications had the greatest association with reoperation (OR 21.9 [20.5-23.4]) and readmission (OR 18.7 [17.6-19.9]). Index pulmonary complications had the strongest association with length of stay (coefficient 9.39 [8.95-9.83]). CONCLUSIONS Different types of index complications are associated with different perioperative outcomes. These data can help identify patients potentially at risk for suboptimal outcomes and can inform pediatric quality improvement interventions. TYPE OF STUDY Cohort study. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Jorge I Portuondo
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E DeBakey VA Medical Center, Houston, TX, United States; Michael E DeBakey Department of Surgery, Baylor College of Medicine, One Baylor Plaza, Suite 404D, Houston, TX 77030, United States.
| | - Steven C Mehl
- Michael E DeBakey Department of Surgery, Baylor College of Medicine, One Baylor Plaza, Suite 404D, Houston, TX 77030, United States; Texas Children's Hospital Department of Surgery, Houston, TX, United States
| | - Sohail R Shah
- Michael E DeBakey Department of Surgery, Baylor College of Medicine, One Baylor Plaza, Suite 404D, Houston, TX 77030, United States; Texas Children's Hospital Department of Surgery, Houston, TX, United States
| | - Mehul V Raval
- Surgical Outcomes and Quality Improvement Center, Center for Healthcare Studies, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, United States; Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Huirong Zhu
- Texas Children's Hospital Department of Surgery, Houston, TX, United States
| | - Sara C Fallon
- Michael E DeBakey Department of Surgery, Baylor College of Medicine, One Baylor Plaza, Suite 404D, Houston, TX 77030, United States; Texas Children's Hospital Department of Surgery, Houston, TX, United States
| | - David E Wesson
- Michael E DeBakey Department of Surgery, Baylor College of Medicine, One Baylor Plaza, Suite 404D, Houston, TX 77030, United States; Texas Children's Hospital Department of Surgery, Houston, TX, United States
| | - Nader N Massarweh
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E DeBakey VA Medical Center, Houston, TX, United States; Michael E DeBakey Department of Surgery, Baylor College of Medicine, One Baylor Plaza, Suite 404D, Houston, TX 77030, United States; Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX, United States
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21
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Matsumoto H, Franzone JM, Sinha R, Roye BD, Glotzbeker MP, Skaggs DL, Flynn JM, Lenke LG, Sponseller PD, Vitale MG. A novel risk calculator predicting surgical site infection after spinal surgery in patients with cerebral palsy. Dev Med Child Neurol 2022; 64:1034-1043. [PMID: 35229288 DOI: 10.1111/dmcn.15193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 01/28/2022] [Accepted: 02/08/2022] [Indexed: 11/30/2022]
Abstract
AIM To develop and validate a risk calculator based on preoperative factors to predict the probability of surgical site infection (SSI) in patients with cerebral palsy (CP) undergoing spinal surgery. METHOD This was a multicenter retrospective cohort study of pediatric patients with CP who underwent spinal fusion. In the development stage, preoperative known factors were collected, and a risk calculator was developed by comparing multiple models and choosing the model with the highest discrimination and calibration abilities. This model was then tested with a separate population in the validation stage. RESULTS Among the 255 patients in the development stage, risk of SSI was 11%. A final prediction model included non-ambulatory status (odds ratio [OR] 4.0), diaper dependence (OR 2.5), age younger than 12 years (OR 2.5), major coronal curve magnitude greater than 90° (OR 1.3), behavioral disorder/delay (OR 1.3), and revision surgery (OR 1.3) as risk factors. This model had a predictive ability of 73.4% for SSI, along with excellent calibration ability (p = 0.878). Among the 390 patients in the validation stage, risk of SSI was 8.2%. The discrimination of the model in the validation phase was 0.743 and calibration was p = 0.435, indicating 74.3% predictive ability and no difference between predicted and observed values. INTERPRETATION This study provides a risk calculator to identify the risk of SSI after spine surgery for patients with CP. This will allow us to enhance decision-making and patient care while providing valid hospital comparisons, public reporting mechanisms, and reimbursement determinations.
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Affiliation(s)
- Hiroko Matsumoto
- Division of Pediatric Orthopaedic Surgery, Department of Orthopaedic Surgery, Columbia University Irving Medical Center, New York, New York, USA.,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Jeanne M Franzone
- Division of Pediatric Orthopaedic Surgery, Department of Orthopaedic Surgery, Columbia University Irving Medical Center, New York, New York, USA
| | - Rishi Sinha
- Division of Pediatric Orthopaedic Surgery, Department of Orthopaedic Surgery, Columbia University Irving Medical Center, New York, New York, USA
| | - Benjamin D Roye
- Division of Pediatric Orthopaedic Surgery, Department of Orthopaedic Surgery, Columbia University Irving Medical Center, New York, New York, USA
| | - Michael P Glotzbeker
- Department of Orthopaedic Surgery, University Hospital Cleveland Medical Center, Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
| | - David L Skaggs
- Spine Center, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - John M Flynn
- Division of Orthopaedic Surgery, Children's Hospital of Philadelphia, Philadelphia, Philadelphia, USA
| | - Lawrence G Lenke
- Division of Pediatric Orthopaedic Surgery, Department of Orthopaedic Surgery, Columbia University Irving Medical Center, New York, New York, USA
| | - Paul D Sponseller
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland, USA.,Bloomberg Children's Center, Baltimore, Maryland, USA
| | - Michael G Vitale
- Division of Pediatric Orthopaedic Surgery, Department of Orthopaedic Surgery, Columbia University Irving Medical Center, New York, New York, USA
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22
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Tejwani R, Lee HJ, Hughes TL, Hobbs KT, Aksenov LI, Scales CD, Routh JC. Predicting postoperative complications in pediatric surgery: A novel pediatric comorbidity index. J Pediatr Urol 2022; 18:291-301. [PMID: 35410802 PMCID: PMC9233007 DOI: 10.1016/j.jpurol.2022.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Revised: 02/25/2022] [Accepted: 03/06/2022] [Indexed: 11/15/2022]
Abstract
INTRODUCTION/BACKGROUND Comorbidity-driven surgical risk assessment is essential for informed patient counseling, risk-stratification, and outcomes-based health-services research. Existing mortality-focused comorbidity indices have had mixed success at risk-adjustment in children. OBJECTIVE To develop a new comorbidity-driven multispecialty surgical risk index predicting 30-day postoperative complications in children. STUDY DESIGN This retrospective cohort study investigated children undergoing surgical procedures across seven specialties in 2014-2015 using the MarketScan® Research databases. The risk index was derived separately for ambulatory and inpatient surgery patients using logistic regression with backward selection. The performance of the novel index in discriminating postoperative complications vis-à-vis three existing comorbidity indices was compared using bootstrapping and area under the receiver operating characteristics curves (AUC). RESULTS We identified 190,629 ambulatory and 22,633 inpatient patients. The novel index had the best performance for discriminating postoperative complications for inpatients (AUC 0.76, 95% confidence interval [CI] 0.75-0.77) relative to the Charlson Comorbidity Index (CCI, 0.56, 95% CI 0.56-0.57), Van Walraven Index (VWI, 0.60, 95% CI 0.60-0.61), and Rhee Score (RS, 0.69, 95% CI 0.68-0.70). In the ambulatory cohort, the novel index outperformed all three existing indices, though none demonstrated excellent discriminatory ability for complications (novel score 0.68, 95% CI 0.67-0.68; CCI 0.53, 95% CI 0.52-0.53; VWI 0.53, 95% CI 0.52-0.53; RS 0.50, 95% CI 0.49-0.50). DISCUSSION In both inpatient and ambulatory pediatric settings, our novel comorbidity index demonstrated better performance at predicting postoperative complications than three widely used alternatives. This index will be useful for research and may be adaptable to clinical settings to identify high-risk patients and facilitate perioperative planning. CONCLUSION We developed a novel pediatric comorbidity index with better performance at predicting postoperative complications than three widely used alternatives.
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Affiliation(s)
- Rohit Tejwani
- Division of Urologic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Hui-Jie Lee
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA
| | - Taylor L Hughes
- Division of Urologic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Kevin T Hobbs
- Division of Urologic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Leonid I Aksenov
- Division of Urologic Surgery, Duke University Medical Center, Durham, NC, USA.
| | - Charles D Scales
- Division of Urologic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Jonathan C Routh
- Division of Urologic Surgery, Duke University Medical Center, Durham, NC, USA
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23
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Matsumoto H, Larson EL, Warren SI, Hammoor BT, Bonsignore-Opp L, Troy MJ, Barrett KK, Striano BM, Li G, Terry MB, Roye BD, Lenke LG, Skaggs DL, Glotzbecker MP, Flynn JM, Roye DP, Vitale MG. A Clinical Risk Model for Surgical Site Infection Following Pediatric Spine Deformity Surgery. J Bone Joint Surg Am 2022; 104:364-375. [PMID: 34851324 DOI: 10.2106/jbjs.21.00751] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Despite tremendous efforts, the incidence of surgical site infection (SSI) following the surgical treatment of pediatric spinal deformity remains a concern. Although previous studies have reported some risk factors for SSI, these studies have been limited by not being able to investigate multiple risk factors at the same time. The aim of the present study was to evaluate a wide range of preoperative and intraoperative factors in predicting SSI and to develop and validate a prediction model that quantifies the risk of SSI for individual pediatric spinal deformity patients. METHODS Pediatric patients with spinal deformity who underwent primary, revision, or definitive spinal fusion at 1 of 7 institutions were included. Candidate predictors were known preoperatively and were not modifiable in most cases; these included 31 patient, 12 surgical, and 4 hospital factors. The Centers for Disease Control and Prevention definition of SSI within 90 days of surgery was utilized. Following multiple imputation and multicollinearity testing, predictor selection was conducted with use of logistic regression to develop multiple models. The data set was randomly split into training and testing sets, and fivefold cross-validation was performed to compare discrimination, calibration, and overfitting of each model and to determine the final model. A risk probability calculator and a mobile device application were developed from the model in order to calculate the probability of SSI in individual patients. RESULTS A total of 3,092 spinal deformity surgeries were included, in which there were 132 cases of SSI (4.3%). The final model achieved adequate discrimination (area under the receiver operating characteristic curve: 0.76), as well as calibration and no overfitting. Predictors included in the model were nonambulatory status, neuromuscular etiology, pelvic instrumentation, procedure time ≥7 hours, American Society of Anesthesiologists grade >2, revision procedure, hospital spine surgical cases <100/year, abnormal hemoglobin level, and overweight or obese body mass index. CONCLUSIONS The risk probability calculator encompassing patient, surgical, and hospital factors developed in the present study predicts the probability of 90-day SSI in pediatric spinal deformity surgery. This validated calculator can be utilized to improve informed consent and shared decision-making and may allow the deployment of additional resources and strategies selectively in high-risk patients. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Hiroko Matsumoto
- Department of Orthopaedic Surgery, Columbia University Irving Medical Center, New York, NY.,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
| | - Elaine L Larson
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY.,School of Nursing, Columbia University Irving Medical Center, New York, NY
| | - Shay I Warren
- Department of Orthopaedic Surgery, Stanford University, Redwood City, California
| | - Bradley T Hammoor
- Department of Orthopaedic Surgery, Columbia University Irving Medical Center, New York, NY
| | - Lisa Bonsignore-Opp
- Department of Orthopaedic Surgery, Columbia University Irving Medical Center, New York, NY
| | - Michael J Troy
- Department of Orthopedic Surgery, Harvard Medical School, Boston, Massachusetts
| | - Kody K Barrett
- Children's Orthopaedic Center, Children's Hospital Los Angeles, Los Angeles, California
| | - Brendan M Striano
- Department of Orthopaedic Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Gen Li
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, Michigan
| | - Mary Beth Terry
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
| | - Benjamin D Roye
- Department of Orthopaedic Surgery, Columbia University Irving Medical Center, New York, NY
| | - Lawrence G Lenke
- Department of Orthopaedic Surgery, Columbia University Irving Medical Center, New York, NY
| | - David L Skaggs
- Spine Center, Cedars-Sinai Medical Center, Los Angeles, California
| | - Michael P Glotzbecker
- Department of Orthopaedic Surgery, Rainbow Babies and Children's Hospital, University Hospital Cleveland Medical Center, Cleveland, Ohio
| | - John M Flynn
- Department of Orthopaedic Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - David P Roye
- Department of Orthopaedic Surgery, Columbia University Irving Medical Center, New York, NY
| | - Michael G Vitale
- Department of Orthopaedic Surgery, Columbia University Irving Medical Center, New York, NY
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24
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Ullrich SJ, Kisa P, Muzira A, Kakembo N, Nabukenya M, Tumukunde J, Sekabira J, Chang DC, Ozgediz D. Pediatric surgical quality improvement in low- and middle-income countries: What data to collect? Surgery 2022; 171:1067-1072. [PMID: 35078626 DOI: 10.1016/j.surg.2021.09.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 09/13/2021] [Accepted: 09/14/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND As surgical access expands in low- and middle-income countries, risk-adjusted outcomes data are needed to measure and improve surgical quality. Existing data collection tools in high-income countries are complex and may be burdensome to implement in low and middle income countries. This study determined the minimum dataset needed for adequate risk adjustment to predict perioperative mortality using data collected in a low- and middle-income countries. METHODS All patients admitted to the pediatric surgery ward at Mulago National Referral Hospital in Kampala, Uganda, from January 1, 2014 through December 31, 2018 were included. Studies were performed modelling the effects of reducing data granularity and reducing number of variables on the area under the receiver operating curve. RESULTS Of the 3,194 patients included, 1,941(61%) were male, 957(30%) were neonates, 1,714 (54%) had an operation, and the overall mortality rate was 14%. Granularity reduction analyses found that measuring age in ranges was equivalent to recording age in days (area under the receiver operating curve = 0.776; 95% confidence interval, 0.754%-0.798%, vs 0.815, 95% confidence interval, 0.794%-0.837%). Variable reduction analyses found that models with 3 predictor variables (diagnosis, procedure, and district) reached a maximum area under the receiver operating curve of 0.915 (95% confidence interval, 0.903%-0.928%), which was equivalent to the model using all available predictor variables (area under the receiver operating curve = 0.932; 95% confidence interval, 0.922%-0.943%). For all 3-variable models, the primary diagnosis contributed most to predictive ability (P < .001). CONCLUSION Effective risk adjustment for perioperative mortality can be performed in low and middle income countries using minimal, objective variables often already part of the patient's medical record. This approach can be used by clinicians, hospital administrators, and policymakers low- and middle-income countries looking to begin data collection to track and improve patient outcomes.
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Affiliation(s)
- Sarah J Ullrich
- Department of Surgery, Yale University School of Medicine, New Haven, CT.
| | - Phyllis Kisa
- Department of Surgery, Mulago National Referral Hospital, Kampala, Uganda
| | - Arlene Muzira
- Department of Surgery, Mulago National Referral Hospital, Kampala, Uganda
| | - Nasser Kakembo
- Department of Surgery, Mulago National Referral Hospital, Kampala, Uganda
| | - Mary Nabukenya
- Department of Anesthesia, Mulago National Referral Hospital, Kampala, Uganda
| | - Janat Tumukunde
- Department of Anesthesia, Mulago National Referral Hospital, Kampala, Uganda
| | - John Sekabira
- Department of Surgery, Mulago National Referral Hospital, Kampala, Uganda
| | - David C Chang
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Doruk Ozgediz
- Department of Surgery, University of California San Francisco, San Francisco, CA
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25
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Buckner J, Cabot J, Fields A, Pounds L, Quint C. Surgical risk calculators in veterans following lower extremity amputation. Am J Surg 2021; 223:1212-1216. [PMID: 34969508 DOI: 10.1016/j.amjsurg.2021.12.008] [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] [Received: 08/19/2021] [Revised: 10/24/2021] [Accepted: 12/06/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate the accuracy of multiple risk calculators for 30-day mortality on patients undergoing major lower extremity amputation. METHODS The actual 30-day mortality at a single Veterans Affairs institution was compared to the predicted outcome from the following risk calculators: ACS-NSQIP, VASQIP, amputation scoring tool (AST), and POTTER elective. RESULTS The overall calculated 30-day mortality was similar to the actual mortality with the VASQIP and POTTER elective risk calculators, while the NSQIP and AST over-estimated the 30-day mortality. The predictive accuracy of the POTTER and NSQIP risk calculators were moderate (AUC >0.7), and fair for the VASQIP and AST. CONCLUSION Risk assessment tools can provide adjunctive data on predicted 30-day mortality in patients undergoing major lower extremity amputation. In our study, there were differences in predictability of the risk calculators for lower extremity amputation that should be considered when utilizing a risk assessment tool to improve physician-patient shared decision-making.
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Affiliation(s)
- Jacob Buckner
- Department of Surgery, Audie Murphy VA Hospital, South Texas Veterans Healthcare System, USA
| | - John Cabot
- Department of Surgery, Audie Murphy VA Hospital, South Texas Veterans Healthcare System, USA
| | - Alyssa Fields
- Department of Vascular and Endovascular Surgery, UT Health San Antonio, San Antonio, TX, 78229, USA
| | - Lori Pounds
- Department of Surgery, Audie Murphy VA Hospital, South Texas Veterans Healthcare System, USA; Department of Vascular and Endovascular Surgery, UT Health San Antonio, San Antonio, TX, 78229, USA
| | - Clay Quint
- Department of Surgery, Audie Murphy VA Hospital, South Texas Veterans Healthcare System, USA; Department of Vascular and Endovascular Surgery, UT Health San Antonio, San Antonio, TX, 78229, USA.
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26
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Does sarcopenia affect outcomes in pediatric surgical patients? A scoping review. J Pediatr Surg 2021; 56:2099-2106. [PMID: 33500162 DOI: 10.1016/j.jpedsurg.2021.01.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 12/06/2020] [Accepted: 01/08/2021] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Adults with sarcopenia have a greater risk of postoperative complications, a higher rate of ICU admission, and an increased length of hospital stay. Few studies have explored the prevalence or importance of sarcopenia in the pediatric population. This study reviews the published literature on sarcopenia in the pediatric population, including pediatric surgery. METHODS Original studies related to sarcopenia in children were identified using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines and the PubMed database. RESULTS A total of 390 articles were screened, with 28 meeting inclusion criteria. Twenty (71%) studies provided a means to define abnormal and 18 studies (64%) showed that a specific disease process could impact lean muscle mass in children. Only 4 (14%) studies associated the change in muscle mass with an outcome. Two studies investigated sarcopenia and outcomes in the pediatric surgical patient and demonstrated associations with worse outcomes. CONCLUSION Despite studies showing an association between sarcopenia and negative outcomes in the adult surgical population, there remains a paucity of evidence regarding the impact of sarcopenia on the pediatric population. Future studies are needed to ascertain the relationship between muscle mass and outcomes in pediatric surgical patients.
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27
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Abstract
BACKGROUND The optimal age for cleft palate repair continues to be debated, with little discussion of surgical risk related to operative timing. This study of 3088 cleft palate patients analyzed the impact of surgical timing on perioperative and 30-day postoperative outcomes. METHODS Primary cleft palate repairs were identified in the National Surgical Quality Improvement Program database from 2012 to 2015. Data were combed for total postoperative complications, rates of readmission and reoperation, operating room time, and length of stay. Bivariate analyses were performed comparing 3-month periods from months 6 to 18, and months 0 to 5, 18 to 23, 24 to 29, and 30 to 59. RESULTS Despite a higher proportion of isolated soft palate closure, children operated on before 6 months had a higher complication rate than children at other ages (7.1 percent versus 3.2 percent; OR, 2.4; p = 0.04), and higher rates of both readmission (3.6 percent versus 1.4 percent; OR, 3.6; p = 0.02) and reoperation (2.4 percent versus 0.5 percent; OR, 4.7; p = 0.04). There were no differences in short-term outcomes for any other age group younger than 5 years, and no differences in hospital length of stay among any age groups. CONCLUSIONS The authors' findings suggest a relative contraindication to operation before 6 months. As there were no differences between any other age groups, long-term speech optimization should continue to be the primary consideration for operative planning. These findings improve the current rationale for palatoplasty timing, and can aid surgeons and parents in the surgical decision-making process. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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28
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Discussion: The Effect of Surgical Timing on 30-Day Outcomes in Cleft Palate Repair. Plast Reconstr Surg 2021; 147:138-140. [PMID: 33370057 DOI: 10.1097/prs.0000000000007459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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29
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Liao K, Chorney SR, Brown AB, Brooks RL, Sewell A, Bailey C, Whitney C, Johnson RF. The Impact of Socioeconomic Disadvantage on Pediatric Tracheostomy Outcomes. Laryngoscope 2021; 131:2603-2609. [PMID: 33860942 DOI: 10.1002/lary.29576] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 03/15/2021] [Accepted: 04/07/2021] [Indexed: 12/19/2022]
Abstract
OBJECTIVES To determine if socioeconomic disadvantage impacts perioperative outcomes after tracheostomy. METHODS We performed a retrospective case series of children who underwent tracheostomy. Children were divided into less and more disadvantaged groups based on their community's Area Deprivation Index (ADI), a validated socioeconomic vulnerability measure. Primary outcomes were the length of stay, total cost, in-hospital mortality, and 30-day all-cause readmission after tracheostomy placement. Length of stay was further analyzed using parametric survival analysis. RESULTS A total of 239 patients met inclusion criteria, with 153 (64%) residing in more disadvantaged communities. Children from more disadvantaged communities were less likely to be White (42% vs. 26%, P = .009) and more likely to have Medicaid coverage (90% vs. 62%, P < .001). The two groups had similar medical complexity and comorbidities. The main outcome measures showed differences in median total length of stay (113 vs. 79 days, P = .04) and median total cost ($461 000 vs. $279 000, P = .01). Children with tracheostomies who were from more disadvantaged communities also had increased risk of prolonged hospitalizations (HR = 0.63, 95% CI = 0.48-0.83, P = .001). Readmissions, mortality rates, and quality of life scores were similar between groups. CONCLUSIONS Community disadvantage was associated with differences in hospitalization length and costs after pediatric tracheostomy placement. Further research should continue to describe how health disparities impact children's safe and efficient care with tracheostomies. LEVEL OF EVIDENCE 4 Laryngoscope, 2021.
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Affiliation(s)
- Kershena Liao
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, U.S.A
| | - Stephen R Chorney
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, U.S.A.,Department of Pediatric Otolaryngology, Children's Health Airway Management Program, Children's Medical Center of Dallas, Dallas, Texas, U.S.A
| | - Ashley B Brown
- Department of Pediatric Otolaryngology, Children's Health Airway Management Program, Children's Medical Center of Dallas, Dallas, Texas, U.S.A
| | - Rebecca L Brooks
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, U.S.A.,Department of Pediatric Otolaryngology, Children's Health Airway Management Program, Children's Medical Center of Dallas, Dallas, Texas, U.S.A
| | - Ashley Sewell
- Department of Pediatric Otolaryngology, Children's Health Airway Management Program, Children's Medical Center of Dallas, Dallas, Texas, U.S.A
| | - Candice Bailey
- Department of Pediatric Otolaryngology, Children's Health Airway Management Program, Children's Medical Center of Dallas, Dallas, Texas, U.S.A
| | - Cindy Whitney
- Department of Pediatric Otolaryngology, Children's Health Airway Management Program, Children's Medical Center of Dallas, Dallas, Texas, U.S.A
| | - Romaine F Johnson
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, U.S.A.,Department of Pediatric Otolaryngology, Children's Health Airway Management Program, Children's Medical Center of Dallas, Dallas, Texas, U.S.A
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30
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Mpody C, Arends J, Aldrink JH, Olutoye OO, Tobias JD, Nafiu OO. Prognostic profiling of children with serious post-operative complications: A novel probability model for failure to rescue. J Pediatr Surg 2021; 56:207-212. [PMID: 33127062 DOI: 10.1016/j.jpedsurg.2020.09.054] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 09/07/2020] [Accepted: 09/13/2020] [Indexed: 01/28/2023]
Abstract
BACKGROUND Failure to rescue (FTR), mortality after a major postoperative complication, is a superior surgical quality metric compared to surgical mortality or complications rates alone. Our objective was to develop and validate a novel pediatric profiling to identify high-risk subjects among the subset of children who develop serious post-operative complications. METHODS We performed a retrospective study of children who developed one or more serious postoperative complications following inpatient surgery across NSQIP-Pediatric hospitals (2012-2017). We evaluated the rate of FTR according to pre-operative comorbidity burden. RESULTS We identified 45,504 surgical cases with major post-operative complications (FTR rates: 2.4%). Surgical cases with greater than six pre-operative comorbidities (n = 12,148;28%) accounted for 80% of FTR events. The expected probability of FTR was 0.1%(95%CI:0.1%-0.2%) among low-risk cases, 3.3%(95%CI:3.0%-3.5%) among intermediate-risk cases, and 22.6%(95%CI:20.9%-24.3%) among high-risk cases. About half of surgical cases in the high-risk profile group died within 48 h of surgery. Comparatively, cases in the intermediate-risk group had a much longer time to mortality (10 days). CONCLUSION We propose a prognostic index to accurately identify children at risk for FTR. The use of such an index may provide surgeons with a window of opportunity to implement aggressive monitoring and therapeutic strategies to reduce mortality. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Christian Mpody
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH
| | - Jordan Arends
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH
| | - Jennifer H Aldrink
- Division of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH
| | - Oluyinka O Olutoye
- Division of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH
| | - Joseph D Tobias
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH
| | - Olubukola O Nafiu
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH.
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31
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Davidson C, Jacob B, Brown A, Brooks R, Bailey C, Whitney C, Chorney S, Lenes-Voit F, Johnson RF. Perioperative Outcomes After Tracheostomy Placement Among Complex Pediatric Patients. Laryngoscope 2021; 131:E2469-E2474. [PMID: 33464608 DOI: 10.1002/lary.29402] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 01/05/2021] [Accepted: 01/06/2021] [Indexed: 12/22/2022]
Abstract
OBJECTIVES/HYPOTHESIS To compare perioperative outcomes after pediatric tracheostomy placement based on patient complexity. STUDY DESIGN Retrospective case series. METHODS All patients that underwent tracheostomy placement at a tertiary children's hospital between 2015 and 2019 were followed. Children with a history of major cardiac surgery, sepsis, or total parental nutrition (TPN) were grouped as complex. Admission length, tracheostomy-related complications, in-hospital mortality, and 30-day readmissions were recorded among complex and non-complex patients. RESULTS A total of 238 children were included. Mean age at tracheostomy was 39.9 months (SD: 61.3), 51% were male and 51% were complex. Complex patients were younger at admission (29.9 vs. 46.8 months, P = .03), more likely to have respiratory failure (81% vs. 53%, P < .001) and more often required mechanical ventilation at discharge (86% vs. 67%, P < .001). An additional 33 days after placement was required for complex children (95% CI: 14-51, P = .001) and this group had more deaths (8% vs. 1%, P = .02); however, both groups had similar complication and readmission rates (P > .05). Total charges were higher among complex patients ($700,267 vs. $338,937, P < .001). Parametric survival analysis identified mechanical ventilation and patient complexity interacting to predict post-tracheostomy admission length. CONCLUSIONS Hospital discharge after pediatric tracheostomy was associated with patient complexity and further influenced by mechanical ventilation. Recognition that cardiac surgery, sepsis, or TPN can predict poorer perioperative outcomes can provide quality improvement strategies for these vulnerable children. LEVEL OF EVIDENCE 4 Laryngoscope, 131:E2469-E2474, 2021.
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Affiliation(s)
- Christian Davidson
- Department of Otolaryngology Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, U.S.A
| | - Benjamin Jacob
- Department of Otolaryngology Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, U.S.A
| | - Ashley Brown
- Children's Health Airway Management Program, Department of Pediatric Otolaryngology, Children's Medical Center Dallas, Dallas, Texas, U.S.A
| | - Rebecca Brooks
- Children's Health Airway Management Program, Department of Pediatric Otolaryngology, Children's Medical Center Dallas, Dallas, Texas, U.S.A
| | - Candace Bailey
- Children's Health Airway Management Program, Department of Pediatric Otolaryngology, Children's Medical Center Dallas, Dallas, Texas, U.S.A
| | - Cindy Whitney
- Children's Health Airway Management Program, Department of Pediatric Otolaryngology, Children's Medical Center Dallas, Dallas, Texas, U.S.A
| | - Stephen Chorney
- Department of Otolaryngology Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, U.S.A.,Children's Health Airway Management Program, Department of Pediatric Otolaryngology, Children's Medical Center Dallas, Dallas, Texas, U.S.A
| | - Felicity Lenes-Voit
- Department of Otolaryngology Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, U.S.A.,Children's Health Airway Management Program, Department of Pediatric Otolaryngology, Children's Medical Center Dallas, Dallas, Texas, U.S.A
| | - Romaine F Johnson
- Department of Otolaryngology Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, U.S.A.,Children's Health Airway Management Program, Department of Pediatric Otolaryngology, Children's Medical Center Dallas, Dallas, Texas, U.S.A
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Bauer JM, Shah SA, Sponseller PD, Samdani AF, Newton PO, Marks MC, Lonner BS, Yaszay B. Comparing short-term AIS post-operative complications between ACS-NSQIP and a surgeon study group. Spine Deform 2020; 8:1247-1252. [PMID: 32720267 DOI: 10.1007/s43390-020-00170-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 07/13/2020] [Indexed: 11/25/2022]
Abstract
STUDY DESIGN Prospective cohort review. OBJECTIVE To compare two AIS databases to determine if a performance improvement-based surgeon group has different outcomes compared to a national database. The American College of Surgeon's National Quality Improvement Program (ACS-NSQIP) and a surgeon study group (SG) collect prospective data on AIS surgery outcomes. NSQIP offers open enrollment to all institutions, and SG membership is limited to 15 high-volume institutions, with a major initiative to improve surgeon performance. While both provide important outcome benchmarks, they may reflect outcomes that are not relatable nationwide. METHODS The ASC-NSQIP Pediatric Spine Fusion and SG database were queried for AIS 30- and 90-day complication data for 2014 and 2015. Prospective enrollment and a dedicated site coordinator with rigorous data quality assurance protocols existed for both registries. Outcomes were compared between groups with respect to superficial and deep surgical site infections (SSI), neurologic injury, readmission, and reoperation. RESULTS There were a total of 2927 AIS patients included in the ASC-NSQIP data and 721 in the SG database. Total complication rate was 9.4% NSQIP and 3.6% SG. At 90 days, there were fewer surgical site infections reported by SG than ASC-NSQIP (0.6% vs. 1.6%, p = 0.03). Similarly, there were less spinal cord injuries (0.8% vs 1.5%, p = 0.006), 30-day readmissions (0.8% vs. 2.6%, p = 0.002), and 30-day reoperations (0.6% vs. 1.7%, p = 0.02) in the SG cohort. CONCLUSIONS Comparison of these two data sets suggests a range of complications and readmission rates, with the SG demonstrating lower values. These results are likely multi-factorial with the performance improvement initiative of the SG playing a role. Understanding the rate and ultimate risk factors for readmission and complications from big data sources has the potential to further drive quality improvement. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Jennifer M Bauer
- Dept. of Orthopaedic Surgery, Seattle Children's Hospital, University of Washington, 4800 Sand Point Way NE, Seattel, WA, 98105, USA.
| | - Suken A Shah
- Nemours/AI duPont Hospital for Children, Wilmington, USA
| | | | - Amer F Samdani
- Philadelphia Shriners Hospital for Children, Philadelphia, USA
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Nasr VG, Valencia E, Staffa SJ, Faraoni D, DiNardo JA, Berry JG, Leahy I, Ferrari L. Comprehensive Risk Assessment of Morbidity in Pediatric Patients Undergoing Noncardiac Surgery: An Institutional Experience. Anesth Analg 2020; 131:1607-1615. [PMID: 33079885 DOI: 10.1213/ane.0000000000005157] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Utilizing the intrinsic surgical risk (ISR) and the patient's chronic and acute conditions, this study aims to develop and validate a comprehensive predictive model of perioperative morbidity in children undergoing noncardiac surgery. METHODS Following institutional review board (IRB) approval at a tertiary care children's hospital, data for all noncardiac surgical encounters for a derivation dataset from July 2017 to December 2018 including 16,724 cases and for a validation dataset from January 2019 to December 2019 including 9043 cases were collected retrospectively. The primary outcome was a composite morbidity score defined by unplanned transfer to an intensive care unit (ICU), acute respiratory failure requiring intubation, postoperative need for noninvasive or invasive positive pressure ventilation, or cardiac arrest. Internal model validation was performed using 1000 bootstrap resamples, and external validation was performed using the 2019 validation cohort. RESULTS A total of 1519 surgical cases (9.1%) experienced the defined composite morbidity. Using multivariable logistic regression, the Risk Assessment of Morbidity in Pediatric Surgery (RAMPS) score was developed with very good predictive ability in the derivation cohort (area under the curve [AUC] = 0.805; 95% confidence interval [CI], 0.795-0.816), very good internal validity using 1000 bootstrap resamples (bias-corrected Nagelkerke R = 0.21 and Brier score = 0.07), and good external validity (AUC = 0.783; 95% CI, 0.770-0.797). The included variables are age <5 years, critically ill, chronic condition indicator (CCI) ≥3, significant CCI ≥2, and ISR quartile ≥3. The RAMPS score ranges from 0 to 10, with the risk of composite morbidity ranging from 1.8% to 42.7%. CONCLUSIONS The RAMPS score provides the ability to identify a high-risk cohort of pediatric patients using a 5-component tool, and it demonstrated good internal and external validity and generalizability. It also provides an opportunity to improve perioperative planning with the intent of improving both individual-patient outcomes and the appropriate allocation of health care resources.
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Affiliation(s)
- Viviane G Nasr
- From the Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Eleonore Valencia
- From the Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Steven J Staffa
- From the Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - David Faraoni
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - James A DiNardo
- From the Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jay G Berry
- Complex Care Service, Division of General Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Izabela Leahy
- From the Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Lynne Ferrari
- From the Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
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Terui K, Hirahara N, Tachimori H, Kato N, Fujishiro J, Watanabe E, Tomita H, Okamoto T, Fujiogi M, Okamoto S, Yonekura T, Miyata H, Usui N. Development and validation of risk models for mortality and morbidity in 12 major pediatric surgical procedures: A study from the National Clinical Database-Pediatric of Japan. J Pediatr Surg 2020; 55:2064-2070. [PMID: 32507636 DOI: 10.1016/j.jpedsurg.2020.03.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 02/22/2020] [Accepted: 03/27/2020] [Indexed: 12/23/2022]
Abstract
PURPOSE To establish and validate risk models of mortality and morbidity associated with 12 major pediatric surgical procedures using the National Clinical Database-Pediatric (NCD-P) data. METHODS We used the NCD-P data for the development and validation datasets. By using multivariate logistic regression to analyze the development dataset, we created a prediction model for 30-day mortality and morbidity in 12 major pediatric surgical procedures, including tracheoplasty, pneumonectomy, fundoplication, total/subtotal excision of malignant tumor, and surgeries for Hirschsprung disease, anorectal malformation, biliary atresia, choledocal cyst, midgut volvulus, funnel chest, gastrointestinal perforation, and intestinal obstruction. We selected variables that were almost identical to those used in the American College of Surgeons National Surgical Quality Improvement Program-Pediatric (NSQIP-P). The primary outcomes were 30-day mortality and composite morbidity. We assessed the obtained models using the C-indices of the development and validation datasets. RESULTS Overall, 10 and 21 variables were identified for mortality and morbidity, respectively. C-indices of mortality were 0.940 and 0.924 in the development and validation datasets, respectively. C-indices of morbidity were 0.832 and 0.830 in the development and validation datasets, respectively. CONCLUSIONS Based on the NCD-P data, we developed satisfactory risk models for mortality and morbidity prediction in major pediatric surgeries. LEVEL OF EVIDENCE Level I (Prognosis Study).
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Affiliation(s)
- Keita Terui
- Department of Pediatric Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan; National Clinical Database Committee and (l)) Pediatric Surgical Database Committee, The Japanese Society of Pediatric Surgeons, Tokyo, Japan.
| | - Norimichi Hirahara
- Department of Healthcare Quality Assessment, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan; National Clinical Database Committee and (l)) Pediatric Surgical Database Committee, The Japanese Society of Pediatric Surgeons, Tokyo, Japan
| | - Hisateru Tachimori
- Department of Healthcare Quality Assessment, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan; Translational Medical Center, National Center of Neurology and Psychiatry, Tokyo, Japan; The Institute for Global Health Policy Research, Bureau of International Health Cooperation, National Center for Global Health and Medicine, Tokyo, Japan
| | - Naohiro Kato
- Translational Medical Center, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Jun Fujishiro
- Department of Pediatric Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan; National Clinical Database Committee and (l)) Pediatric Surgical Database Committee, The Japanese Society of Pediatric Surgeons, Tokyo, Japan
| | - Eiichiro Watanabe
- Department of Pediatric Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan; National Clinical Database Committee and (l)) Pediatric Surgical Database Committee, The Japanese Society of Pediatric Surgeons, Tokyo, Japan
| | - Hirofumi Tomita
- Department of Surgery, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan; National Clinical Database Committee and (l)) Pediatric Surgical Database Committee, The Japanese Society of Pediatric Surgeons, Tokyo, Japan
| | - Tatsuya Okamoto
- Department of Hepato-Biliary-Pancreatic Surgery and Transplantation, Graduate School of Medicine, Kyoto University, Kyoto, Japan; National Clinical Database Committee and (l)) Pediatric Surgical Database Committee, The Japanese Society of Pediatric Surgeons, Tokyo, Japan
| | - Michimasa Fujiogi
- Department of Pediatric Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan; National Clinical Database Committee and (l)) Pediatric Surgical Database Committee, The Japanese Society of Pediatric Surgeons, Tokyo, Japan
| | - Shinya Okamoto
- Department of Pediatric Surgery, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Japan; National Clinical Database Committee and (l)) Pediatric Surgical Database Committee, The Japanese Society of Pediatric Surgeons, Tokyo, Japan
| | - Takeo Yonekura
- Department of Pediatric Surgery, Kindai University School of Medicine Nara Hospital, Nara, Japan; National Clinical Database Committee and (l)) Pediatric Surgical Database Committee, The Japanese Society of Pediatric Surgeons, Tokyo, Japan
| | - Hiroaki Miyata
- Department of Healthcare Quality Assessment, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Noriaki Usui
- Department of Pediatric Surgery, Osaka Women's and Children's Hospital, Izumi, Japan; National Clinical Database Committee and (l)) Pediatric Surgical Database Committee, The Japanese Society of Pediatric Surgeons, Tokyo, Japan
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Nafiu OO, Mpody C, Kim SS, Uffman JC, Tobias JD. Race, Postoperative Complications, and Death in Apparently Healthy Children. Pediatrics 2020; 146:peds.2019-4113. [PMID: 32690804 DOI: 10.1542/peds.2019-4113] [Citation(s) in RCA: 91] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/06/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND That African American (AA) patients have poorer surgical outcomes compared with their white peers is established. The prevailing presumption is that these disparities operate within the context of a higher preoperative comorbidity burden among AA patients. Whether these racial differences in outcomes exist among apparently healthy children (traditionally expected to have low risk of postsurgical complications) has not been previously investigated. METHODS We performed a retrospective study by analyzing the National Surgical Quality Improvement Program-Pediatric database from 2012 through 2017 and identifying children who underwent inpatient operations and were assigned American Society of Anesthesiologists physical status 1 or 2. We used univariable and risk-adjusted logistic regression to estimate the odds ratios and their 95% confidence intervals (CIs) of postsurgical outcomes comparing AA to white children. RESULTS Among 172 549 apparently healthy children, the incidence of 30-day mortality, postoperative complications, and serious adverse events were 0.02%, 13.9%, and 5.7%, respectively. Compared with their white peers, AA children had 3.43 times the odds of dying within 30 days after surgery (odds ratio: 3.43; 95% CI: 1.73-6.79). Compared with being white, AA had 18% relative greater odds of developing postoperative complications (odds ratio: 1.18; 95% CI: 1.13-1.23) and 7% relative higher odds of developing serious adverse events (odds ratio: 1.07; 95% CI: 1.01-1.14). CONCLUSIONS Even among apparently healthy children, being AA is strongly associated with a higher risk of postoperative complications and mortality. Mechanisms underlying the established racial differences in postoperative outcomes may not be fully explained by the racial variation in preoperative comorbidity.
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Affiliation(s)
- Olubukola O Nafiu
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio
| | - Christian Mpody
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio
| | - Stephani S Kim
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio
| | - Joshua C Uffman
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio
| | - Joseph D Tobias
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio
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Mpody C, Humphrey L, Kim S, Tobias JD, Nafiu OO. Racial Differences in Do-Not-Resuscitate Orders among Pediatric Surgical Patients in the United States. J Palliat Med 2020; 24:71-76. [PMID: 32543271 DOI: 10.1089/jpm.2020.0053] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Very few studies have investigated the racial differences in do-not-resuscitate (DNR) orders in children, and these studies are limited to oncological cases. We aim to characterize the racial difference in DNR orders among U.S. pediatric surgical patients. Methods: We retrospectively evaluated the mortality of all children who underwent an inpatient surgery between 2012 and 2017 from the National Surgical Quality Improvement Program. We used log-binomial models to estimate the relative risk (RR) and 95% confidence interval (CI) of DNR use comparing white with African American (AA) children. To estimate the risk-adjusted difference in DNR orders, we controlled the analyses for age, prematurity status, emergent case status, American Society of Anesthesiologists class, year of operation, surgical specialty, and surgical complexity. Results: Between 2012 and 2017, a total of 276,917 children underwent inpatient surgery, of whom 0.8% (n = 1601) died within 30 days of operation. Of the 1601 mortality cases, we retained 1212 children who were of either AA (26.0%, n = 350) or white (63.9%, n = 862) race. Most children were neonates, had an American Society of Anesthesiologists class ≥4 (70.0%, n = 811), and developed one or more postoperative complications (68.7%, n = 833). Overall, AA children were more likely to be neonates at the time of surgery (42.0% vs. 40.3%, p < 0.001), to be premature (66.3% vs. 49.0%, p < 0.001), and develop one or more postoperative complications (73.7% vs. 66.7%, p = 0.017). White children were three times more likely to have a DNR order than their AA peers (adjusted RR: 3.01, 95% CI: 1.09-8.56, p = 0.044). Conclusion: Among pediatric surgical patients in the United States, children of white race were three times more likely to have a DNR order in place than their AA peers despite the latter being "sicker" and more likely to develop postoperative complications. The mechanisms underlying this racial difference deserve further elucidation to improve shared decision making and goal-concordant care.
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Affiliation(s)
- Christian Mpody
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Lisa Humphrey
- Division of Palliative Care, Department of Pediatrics, The Ohio State University, Columbus, Ohio, USA
| | - Stephani Kim
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Joseph D Tobias
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Olubukola O Nafiu
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA
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Parkin CJ, Moritz P, Kirkland O, Doane M, Glover A. Utility of the American College of Surgeons National Surgical Quality Improvement Program surgical risk calculator in predicting mortality in an Australian acute surgical unit. ANZ J Surg 2020; 90:746-751. [DOI: 10.1111/ans.15892] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 03/09/2020] [Accepted: 03/19/2020] [Indexed: 12/13/2022]
Affiliation(s)
- Cameron J. Parkin
- Department of Surgery and Surgical Education Research and Training InstituteRoyal North Shore Hospital, Northern Sydney Local Health District Sydney New South Wales Australia
- Northern Clinical School, Faculty of Medicine and HealthSydney Medical School, The University of Sydney Sydney New South Wales Australia
| | - Peter Moritz
- Department of Surgery and Surgical Education Research and Training InstituteRoyal North Shore Hospital, Northern Sydney Local Health District Sydney New South Wales Australia
| | - Olivia Kirkland
- Department of Surgery and Surgical Education Research and Training InstituteRoyal North Shore Hospital, Northern Sydney Local Health District Sydney New South Wales Australia
| | - Matthew Doane
- Northern Clinical School, Faculty of Medicine and HealthSydney Medical School, The University of Sydney Sydney New South Wales Australia
- Department of AnaesthesiaRoyal North Shore Hospital, Northern Sydney Local Health District Sydney New South Wales Australia
| | - Anthony Glover
- Department of Surgery and Surgical Education Research and Training InstituteRoyal North Shore Hospital, Northern Sydney Local Health District Sydney New South Wales Australia
- Northern Clinical School, Faculty of Medicine and HealthSydney Medical School, The University of Sydney Sydney New South Wales Australia
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McLoughlin RJ, Dacier BM, Hazeltine MD, Hirsh MP, Sullivan KP, Cleary MA, Aidlen JT. Intraventricular Hemorrhage and Patent Ductus Arteriosus Ligation Association with Infant Mortality. J Surg Res 2020; 252:192-199. [PMID: 32278974 DOI: 10.1016/j.jss.2020.03.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 02/28/2020] [Accepted: 03/10/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Practice patterns for the management of patent ductus arteriosus (PDA) in premature infants are changing with advances in medical management. We sought to determine the increased mortality for premature infants who had a PDA ligation with a co-existing diagnosis of intraventricular hemorrhage (IVH). METHODS Premature neonates (<1 y old with known gestational week ≤36 wk) with a diagnosis of IVH were identified within the Kids' Inpatient Database (KID) for the years 2006, 2009, and 2012. Diagnoses and procedures were analyzed by ICD-9 codes and stratified by a diagnosis of PDA and procedure of ligation. Case weighting was used to make national estimations. Multivariable logistic regression was performed to adjust for confounders. RESULTS We identified 7567 hospitalizations for premature neonates undergoing PDA ligation. The population was predominately male (51.6%), non-Hispanic white (41.1%), were from the lowest income quartile (33.1%), had a gestational week of 25-26 wk (34.0%), and a birthweight between 500 and 749 g (37.3%). There was an increased mortality (10.7% versus 6.3%, P < 0.01) and an increased length of stay (88.2 d versus 74.4 d, P < 0.01) in those with any diagnosis of IVH compared with those without. Adjusted multivariable logistic regression demonstrated that high-grade IVH (III or IV) was associated with a significantly increased risk of mortality in those undergoing PDA ligation (aOR 2.59, P < 0.01). Specifically, grade III and IV were associated with an increased odds of in-hospital mortality (aOR 1.99 and 3.16, respectively, P < 0.01). CONCLUSIONS Attitudes regarding the need for surgical intervention for PDA have shifted in recent years. This study highlights that premature neonates with grade III or IV IVH are at significantly increased risk of mortality if undergoing PDA ligation during the same hospitalization. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Robert J McLoughlin
- Department of Surgery, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Brittany M Dacier
- University of Massachusetts Medical School, Worcester, Massachusetts
| | - Max D Hazeltine
- Department of Surgery, University of Massachusetts Medical School, Worcester, Massachusetts.
| | - Michael P Hirsh
- Division of Pediatric Surgery, Department of Surgery, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Katherine P Sullivan
- Division of Neonatology, Department of Pediatrics, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Muriel A Cleary
- Division of Pediatric Surgery, Department of Surgery, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Jeremy T Aidlen
- Division of Pediatric Surgery, Department of Surgery, University of Massachusetts Medical School, Worcester, Massachusetts
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Ingram M, Short HL, Sathya C, Fevrier H, Raval MV. Hospital-level factors associated with nonoperative management in common pediatric surgical procedures. J Pediatr Surg 2020; 55:609-614. [PMID: 31708206 DOI: 10.1016/j.jpedsurg.2019.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 09/18/2019] [Accepted: 10/19/2019] [Indexed: 11/25/2022]
Abstract
PURPOSE Our purpose was to examine patient- and hospital-level factors associated with nonoperative management in common pediatric surgical diagnoses. METHODS Using the 2012 Kid's Inpatient Database (KID), we identified patients <20 years old diagnosed with cholecystitis (CHOL), bowel obstruction (BO), perforated appendicitis (PA), or spontaneous pneumothorax (SPTX). Logistic regression models were used to identify factors associated with nonoperative management. RESULTS Of 36,026 admissions for the diagnoses of interest, 7472 (20.7%) were managed nonoperatively. SPTX had the highest incidence of NONOP (55.9%; n = 394), while PA had the lowest incidence (9.2%; n = 1641). Utilization of operative management varied significantly between hospitals. Patients diagnosed with BO (OR 0.41; 95% CI 0.30-0.56) and SPTX (OR 0.28; 95% CI 0.14-0.56) had decreased odds of operative management when treated at an urban, teaching hospital compared to a rural hospital. Patients with PA had increased odds of operative management when treated at an urban, teaching hospital (OR 2.42; 95% CI 1.78-3.30). Hospital-level factors associated with decreased odds of nonoperative management included urban, nonteaching status (OR 0.54; 95% CI 0.31-0.91) and location in the South (OR 0.53; 95% CI 0.34-83) and West (OR 0.47; 95% CI 0.30-0.74). CONCLUSIONS Despite representing more than 20% of pediatric surgical care for several conditions, nonoperative management is an understudied aspect of care with significant variation that warrants further research. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Martha Ingram
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Heather L Short
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Chethan Sathya
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Helene Fevrier
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Mehul V Raval
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.
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Vaziri S, Abbatematteo JM, Fleisher MS, Dru AB, Lockney DT, Kubilis PS, Hoh DJ. Correlation of perioperative risk scores with hospital costs in neurosurgical patients. J Neurosurg 2020; 132:818-824. [PMID: 30771769 DOI: 10.3171/2018.10.jns182041] [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: 07/15/2018] [Accepted: 10/24/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) online surgical risk calculator uses inherent patient characteristics to provide predictive risk scores for adverse postoperative events. The purpose of this study was to determine if predicted perioperative risk scores correlate with actual hospital costs. METHODS A single-center retrospective review of 1005 neurosurgical patients treated between September 1, 2011, and December 31, 2014, was performed. Individual patient characteristics were entered into the NSQIP calculator. Predicted risk scores were compared with actual in-hospital costs obtained from a billing database. Correlational statistics were used to determine if patients with higher risk scores were associated with increased in-hospital costs. RESULTS The Pearson correlation coefficient (R) was used to assess the correlation between 11 types of predicted complication risk scores and 5 types of encounter costs from 1005 health encounters involving neurosurgical procedures. Risk scores in categories such as any complication, serious complication, pneumonia, cardiac complication, surgical site infection, urinary tract infection, venous thromboembolism, renal failure, return to operating room, death, and discharge to nursing home or rehabilitation facility were obtained. Patients with higher predicted risk scores in all measures except surgical site infection were found to have a statistically significant association with increased actual in-hospital costs (p < 0.0005). CONCLUSIONS Previous work has demonstrated that the ACS NSQIP surgical risk calculator can accurately predict mortality after neurosurgery but is poorly predictive of other potential adverse events and clinical outcomes. However, this study demonstrates that predicted high-risk patients identified by the ACS NSQIP surgical risk calculator have a statistically significant moderate correlation to increased actual in-hospital costs. The NSQIP calculator may not accurately predict the occurrence of surgical complications (as demonstrated previously), but future iterations of the ACS universal risk calculator may be effective in predicting actual in-hospital costs, which could be advantageous in the current value-based healthcare environment.
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Affiliation(s)
- Sasha Vaziri
- 2Department of Neurosurgery, University of Florida, Gainesville, Florida
| | | | | | - Alexander B Dru
- 2Department of Neurosurgery, University of Florida, Gainesville, Florida
| | - Dennis T Lockney
- 2Department of Neurosurgery, University of Florida, Gainesville, Florida
| | - Paul S Kubilis
- 2Department of Neurosurgery, University of Florida, Gainesville, Florida
| | - Daniel J Hoh
- 2Department of Neurosurgery, University of Florida, Gainesville, Florida
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Valencia E, Staffa SJ, Faraoni D, DiNardo JA, Nasr VG. Prospective External Validation of the Pediatric Risk Assessment Score in Predicting Perioperative Mortality in Children Undergoing Noncardiac Surgery. Anesth Analg 2020; 129:1014-1020. [PMID: 31082968 DOI: 10.1213/ane.0000000000004197] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Early identification of children at high risk for perioperative mortality could lead to improved outcomes; however, there is a lack of well-validated risk prediction tools. The Pediatric Risk Assessment (PRAm) score is a new model to prognosticate perioperative risk of mortality in pediatric patients undergoing noncardiac surgery. It was derived from the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) Pediatric database. In this study, we aimed to externally validate the PRAm score at 1 large institution. METHODS A PRAm score was prospectively assigned by the primary anesthesia team to children ≤18 years of age undergoing noncardiac surgery between July 2017 and July 2018 at a tertiary care pediatric hospital. The primary outcome was the PRAm score's ability to predict 30-day mortality. The area under the receiver operating characteristic (ROC) curve was utilized to determine discriminative ability. Sensitivity and specificity at varying cutoffs were considered. Youden J index and the gray zone approach were applied to determine the optimal PRAm cutoff for predicting 30-day mortality. RESULTS Among the 13,530 cases included in the external validation cohort, the incidence of 30-day mortality was 0.21% (29/13,530). The PRAm score was found to predict 30-day mortality with an area under the curve (AUC) of 0.956 (95% confidence interval [CI], 0.938-0.974; P < .001). Youden J index determined the optimal PRAm score threshold to be ≥5 with a sensitivity of 86% and a specificity of 91%. The gray zone identified an inconclusive risk of mortality in 6.93% (938/13,530) of patients who had PRAm scores of 4 or 5 (sensitivity or specificity <90%, respectively), therefore refining the optimal cutoff point to be a PRAm score of ≥6. The incidence of mortality for patients with an American Society of Anesthesiologists Physical Status (ASA PS) ≤3 (0.06%, 8/13,530) increased 8-fold for those with an ASA PS of ≤3 and a PRAm score of ≥6. CONCLUSIONS The PRAm score is a simple and objective tool that has excellent ability to predict perioperative risk of mortality in pediatric patients undergoing noncardiac surgery and can be easily used by clinicians. The application of the PRAm score could have important implications on the safety and quality of care delivered to infants and children and on the resource utilization in the pediatric health care system.
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Affiliation(s)
- Eleonore Valencia
- From the Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Steven J Staffa
- From the Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - David Faraoni
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - James A DiNardo
- From the Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Viviane G Nasr
- From the Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
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Raymond BL, Wanderer JP, Hawkins AT, Geiger TM, Ehrenfeld JM, Stokes JW, McEvoy MD. Use of the American College of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator During Preoperative Risk Discussion: The Patient Perspective. Anesth Analg 2019; 128:643-650. [PMID: 30169413 DOI: 10.1213/ane.0000000000003718] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND The American College of Surgeons (ACS) National Surgical Quality Improvement Program Surgical Risk Calculator (ACS Calculator) provides empirically derived, patient-specific risks for common adverse perioperative outcomes. The ACS Calculator is promoted as a tool to improve shared decision-making and informed consent for patients undergoing elective operations. However, to our knowledge, no data exist regarding the use of this tool in actual preoperative risk discussions with patients. Accordingly, we performed a survey to assess (1) whether patients find the tool easy to interpret, (2) how accurately patients can predict their surgical risks, and (3) the impact of risk disclosure on levels of anxiety and future motivations to decrease personal risk. METHODS Patients (N = 150) recruited from a preoperative clinic completed an initial survey where they estimated their hospital length of stay and personal perioperative risks of the 12 clinical complications analyzed by the ACS Calculator. Next, risk calculation was performed by entering participants' demographics into the ACS Calculator. Participants reviewed their individualized risk reports in detail and then completed a follow-up survey to evaluate their perceptions. RESULTS Nearly 90% of participants desire to review their ACS Calculator report before future surgical consents. High-risk patients were 3 times more likely to underestimate their risk of any complication, serious complication, and length of stay compared to low-risk patients (P < .001). After reviewing their calculated risks, 70% stated that they would consider participating in prehabilitation to decrease perioperative risk, and nearly 40% would delay their surgery to do so. Knowledge of personal ACS risk calculations had no effect on anxiety in 20% and decreased anxiety in 71% of participants. CONCLUSIONS The ACS Calculator may be of particular benefit to high-risk surgical populations by providing realistic expectations of outcomes and recovery. Use of this tool may also provide motivation for patients to participate in risk reduction strategies.
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Affiliation(s)
| | | | | | - Timothy M Geiger
- General Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - John W Stokes
- General Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
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Eisler LD, Hua M, Li G, Sun LS, Kim M. A Multivariable Model Predictive of Unplanned Postoperative Intubation in Infant Surgical Patients. Anesth Analg 2019; 129:1645-1652. [PMID: 31743186 PMCID: PMC6894615 DOI: 10.1213/ane.0000000000004043] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Unplanned postoperative intubation is an important quality indicator, and is associated with significantly increased mortality in children. Infant patients are more likely than older pediatric patients to experience unplanned postoperative intubation, yet the literature provides few characterizations of this outcome in our youngest patients. The objective of this study was to identify risk factors for unplanned postoperative intubation and to develop a scoring system to predict this complication in infants undergoing major surgical procedures. METHODS In this retrospective cohort study, The National Surgical Quality Improvement Program-Pediatric database was surveyed for all infants who underwent noncardiac surgery between January 1, 2012 and December 31, 2015 (derivation cohort, n = 56,962) and between January 1 and December 31, 2016 (validation cohort, n = 20,559). Demographic and perioperative clinical characteristics were examined in association with our primary outcome of unplanned postoperative intubation within 30 days of surgery. Risk factors were analyzed in the derivation cohort (2012-2015 data) using multivariable logistic regression with stepwise selection. Parameters from the final model were used to create a scoring system for predicting unplanned postoperative intubation. Data from the validation cohort were utilized to assess the performance of the scoring system using the area under the receiver operating characteristic curve. RESULTS In the derivation cohort, 2.2% of the infants experienced unplanned postoperative intubation within 30 days of surgery. Of the 14 risk factors identified in multivariable analysis, 10 (age, prematurity, American Society of Anesthesiologists physical status, inpatient status, operative time >120 minutes, cardiac disease, malignancy, hematologic disorder, oxygen supplementation, and nutritional support) were included in the final multivariable logistic regression model to create the risk score. The area under the receiver operating characteristic curve of the final model was 0.86 (95% CI, 0.85-0.87) for the derivation cohort and 0.83 (95% CI, 0.82-0.85) for the validation cohort. CONCLUSIONS About 1 in 50 infants undergoing major surgical procedures experiences unplanned postoperative intubation. Our scoring system based on routinely collected perioperative assessment data can predict risk in infants with good accuracy. Further investigation should assess the clinical utility of the scoring system for risk stratification and improvement in perioperative care quality and patient outcomes.
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Affiliation(s)
- Lisa D. Eisler
- Department of Anesthesiology, Columbia University Medical Center, New York, New York
| | - May Hua
- Department of Anesthesiology, Columbia University Medical Center, New York, New York
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | - Guohua Li
- Department of Anesthesiology, Columbia University Medical Center, New York, New York
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | - Lena S. Sun
- Department of Anesthesiology, Columbia University Medical Center, New York, New York
- Department of Pediatrics, Columbia University Medical Center, New York, New York
| | - Minjae Kim
- Department of Anesthesiology, Columbia University Medical Center, New York, New York
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
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Wound Complications, Additional Ventilation Requirement, Prolonged Stay, and Readmission in Primary Palatoplasty. Plast Reconstr Surg 2019; 144:1150-1157. [DOI: 10.1097/prs.0000000000006163] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Benzon HA, Bobrowski A, Suresh S, Wasson NR, Cheon EC. Impact of preoperative hyponatraemia on paediatric perioperative mortality. Br J Anaesth 2019; 123:618-626. [DOI: 10.1016/j.bja.2019.07.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Revised: 06/28/2019] [Accepted: 07/22/2019] [Indexed: 10/26/2022] Open
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Artificial Intelligence Methods for Surgical Site Infection: Impacts on Detection, Monitoring, and Decision Making. Surg Infect (Larchmt) 2019; 20:546-554. [DOI: 10.1089/sur.2019.150] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
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Development and Validation of Extracorporeal Membrane Oxygenation Mortality-Risk Models for Congenital Diaphragmatic Hernia. ASAIO J 2019; 64:785-794. [PMID: 29117038 PMCID: PMC5938163 DOI: 10.1097/mat.0000000000000716] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
The purpose of our study was to develop and validate extracorporeal membrane oxygenation (ECMO)–specific mortality risk models for congenital diaphragmatic hernia (CDH). We utilized the data from the Extracorporeal Life Support Organization Registry (2000–2015). Prediction models were developed using multivariable logistic regression. We identified 4,374 neonates with CDH with an overall mortality of 52%. Predictive discrimination (C statistic) for pre-ECMO mortality model was C = 0.65 (95% confidence interval, 0.62–0.68). Within the highest risk group, based on the pre-ECMO risk score, mortality was 87% and 75% in the training and validation data sets, respectively. The pre-ECMO risk score included pre-ECMO ventilator settings, pH, prior diaphragmatic hernia repair, critical congenital heart disease, perinatal infection, and demographics. For the on-ECMO model, mortality prediction improved substantially: C = 0.73 (95% confidence interval, 0.71–0.76) with the addition of on-ECMO–associated complications. Within the highest risk group, defined by the on-ECMO risk score, mortality was 90% and 86% in the training and validation data sets, respectively. Mortality among neonates with CDH needing ECMO can be reliably predicted with validated clinical variables identified in this study. ECMO-specific mortality prediction tools can allow risk stratification to be used in research and quality improvement efforts, as well as with caution for individual case management.
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Pediatric Risk Stratification Is Improved by Integrating Both Patient Comorbidities and Intrinsic Surgical Risk. Anesthesiology 2019; 130:971-980. [DOI: 10.1097/aln.0000000000002659] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Abstract
Editor’s Perspective
What We Already Know about This Topic
What This Article Tells Us That Is New
Background
Recently developed risk stratification models for perioperative mortality incorporate patient comorbidities as predictors but fail to consider the intrinsic risk of surgical procedures. In this study, the authors used the American College of Surgeons National Surgical Quality Improvement Program Pediatric database to demonstrate the relationship between the intrinsic surgical risk and 30-day mortality and develop and validate an accessible risk stratification model that includes the surgical procedures in addition to the patient comorbidities and physical status.
Methods
A retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Program Pediatric database was performed. The incidence of 30-day mortality was the primary outcome. Surgical Current Procedural Terminology codes with at least 25 occurrences were included. Multivariable logistic regression model was used to determine the predictors for mortality including patient comorbidities and intrinsic surgical risk. An internal validation using bootstrap resampling, and an external validation of the model were performed.
Results
The authors analyzed 367,065 surgical cases encompassing 659 unique Current Procedural Terminology codes with an incidence of overall 30-day mortality of 0.34%. Intrinsic risk of surgical procedures represented by Current Procedural Terminology risk quartiles instead of broad categorization was significantly associated with 30-day mortality (P < 0.001). Predicted risk of 30-day mortality ranges from 0% with no comorbidities to 4.7% when all comorbidities are present among low-risk surgical procedures and from 0.07 to 46.7% among high-risk surgical procedures. Using an external validation cohort of 110,474 observations, the multivariable predictive risk model displayed good calibration and excellent discrimination with area under curve (c-index) equals 0.95 (95% CI, 0.94 to 0.96; P < 0.001).
Conclusions
Understanding and accurately estimating perioperative risk by accounting for the intrinsic risk of surgical procedures and patient comorbidities will lead to a more comprehensive discussion between patients, families, and providers and could potentially be used to conduct cost analysis and allocate resources.
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Berry JG, Johnson C, Crofton C, Staffa SJ, DiTillio M, Leahy I, Salem J, Rangel SJ, Singer SJ, Ferrari L. Predicting Postoperative Physiologic Decline After Surgery. Pediatrics 2019; 143:peds.2018-2042. [PMID: 30824493 DOI: 10.1542/peds.2018-2042] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/11/2019] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Projecting postoperative recovery in pediatric surgical patients is challenging. We assessed how the patients' number of complex chronic conditions (CCCs) and chronic medications interacted with active health issues to influence the likelihood of postoperative physiologic decline (PoPD). METHODS A prospective study of 3295 patients undergoing elective surgery at a freestanding children's hospital. During preoperative clinical evaluation, active health problems, CCCs, and medications were documented. PoPD (compromise of cardiovascular, respiratory, and/or neurologic systems) was measured prospectively every 4 hours by inpatient nurses. PoPD odds were estimated with multivariable logistic regression. Classification and regression tree analysis distinguished children with the highest and lowest likelihood of PoPD. RESULTS Median age at surgery was 8 years (interquartile range: 2-15); 2336 (70.9%) patients had a CCC; and 241 (7.3%) used ≥11 home medications. During preoperative evaluation, 1556 (47.2%) patients had ≥1 active health problem. After surgery, 882 (26.8%) experienced PoPD. The adjusted odds of PoPD were 1.2 (95% confidence interval [CI]: 1.0-1.4) for presence versus absence of an active health problem; 1.4 (95% CI: 1.0-1.9) for ≥11 vs 0 home medications; and 2.2 (95% CI: 1.7-2.9) for ≥3 vs 0 CCCs. In classification and regression tree analysis, the lowest rate of PoPD (8.6%) occurred in children without an active health problem at the preoperative evaluation; the highest rate (57.2%) occurred in children with a CCC who used ≥11 home medications. CONCLUSIONS Greater than 1 in 4 pediatric patients undergoing elective surgery experienced PoPD. Combinations of active health problems at preoperative evaluation, polypharmacy, and multimorbidity distinguished patients with a low versus high risk of PoPD.
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Affiliation(s)
- Jay G Berry
- Division of General Pediatrics, Complex Care Service and .,Harvard Medical School, Boston, Massachusetts
| | - Connor Johnson
- Departments of Anesthesiology, Critical Care, and Pain Medicine and
| | - Charis Crofton
- Division of General Pediatrics, Complex Care Service and
| | - Steven J Staffa
- Departments of Anesthesiology, Critical Care, and Pain Medicine and
| | - Maura DiTillio
- Departments of Anesthesiology, Critical Care, and Pain Medicine and
| | - Izabela Leahy
- Harvard Medical School, Boston, Massachusetts.,Departments of Anesthesiology, Critical Care, and Pain Medicine and
| | - Joseph Salem
- Healthcare Systems Engineering Institute, Northeastern University, Boston, Massachusetts; and
| | - Shawn J Rangel
- Harvard Medical School, Boston, Massachusetts.,Surgery, Boston Children's Hospital, Boston, Massachusetts
| | - Sara J Singer
- Department of Medicine, School of Medicine, Stanford University, Stanford, California
| | - Lynne Ferrari
- Harvard Medical School, Boston, Massachusetts.,Departments of Anesthesiology, Critical Care, and Pain Medicine and
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Abstract
Text fields in electronic medical records (EMR) contain information on important factors that influence health outcomes, however, they are underutilized in clinical decision making due to their unstructured nature. We analyzed 6497 inpatient surgical cases with 719,308 free text notes from Le Bonheur Children’s Hospital EMR. We used a text mining approach on preoperative notes to obtain a text-based risk score to predict death within 30 days of surgery. In addition, we evaluated the performance of a hybrid model that included the text-based risk score along with structured data pertaining to clinical risk factors. The C-statistic of a logistic regression model with five-fold cross-validation significantly improved from 0.76 to 0.92 when text-based risk scores were included in addition to structured data. We conclude that preoperative free text notes in EMR include significant information that can predict adverse surgery outcomes.
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