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Hall DE, Roberts KB, Charney E. Rethinking the Timetable for Spontaneous Closure of Pediatric Umbilical Hernia. JAMA Pediatr 2024; 178:838-839. [PMID: 38884968 DOI: 10.1001/jamapediatrics.2024.1688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/18/2024]
Affiliation(s)
- David E Hall
- Medical University of South Carolina, Charleston
| | | | - Evan Charney
- University of Massachusetts School of Medicine, Worcester
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Hadj-Youssef S, Rondeau F, Golo KT, Ghali N, Laberge M, Li P, Beltempo M, Lacroix G, Wissanji H. Provincial Review of Adherence to Age-specific Guidelines for Umbilical Hernia Repair and Trends in Management. J Pediatr Surg 2024; 59:791-799. [PMID: 38418272 DOI: 10.1016/j.jpedsurg.2024.01.035] [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: 01/10/2024] [Accepted: 01/22/2024] [Indexed: 03/01/2024]
Abstract
BACKGROUND Umbilical hernia (UH) is a common pediatric condition, for which delaying surgical repair for asymptomatic UH until after age 3 is recommended due to a high incidence of spontaneous closure. We aimed to determine the adherence to guidelines, rate of urgent surgical repair, outcomes, cost, and interinstitutional referral patterns of UH repair in the province of Quebec (Canada). METHODS This was a population-based retrospective cohort study of children 28 days to 17 years old who underwent UH repair between 2010 and 2020 using health administrative databases. Children who had multiple procedures, or prolonged peri-operative stays were excluded. Early repair was defined as elective surgery at or under age 3. RESULTS Of the 3215 children, 1744 (54.2%) were female, and 1872 (58.2%) were treated in a tertiary children's hospital. Guidelines were respected for 2853 out of 3215 children (89.7%). Patients living over 75 km from their treating hospitals (OR 2.36, 95% CI 1.33-4.16, P < 0.01), with pre-existing comorbidities (OR, 2.82; 95% CI, 1.96-4.05; P < 0.001), or being treated in a tertiary center (OR 2.10, 95% CI 1.45-3.03, P < 0.001) had a higher risk of early repair. Repair at or under age 3 and urgent surgery were associated with significant cost increases of 411$ (P < 0.001) and 558$ (P < 0.001), respectively. CONCLUSION Quebec has a high rate of adherence to age-specific guidelines for UH repair. Future research should explore factors that explain transfers into tertiary centers, and the extent to which these reflect efficient use of resources. LEVEL OF EVIDENCE level III. TYPE OF STUDY Retrospective comparative study.
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Affiliation(s)
- Shadi Hadj-Youssef
- School of Medicine, Faculty of Medicine and Health Sciences, McGill University, 3605 Rue de la Montagne, Montréal, QC, Canada
| | - Félix Rondeau
- Department of Economics, Université Laval, Pavillon Charles-De Koninck, 1030 Av. des Sciences Humaines, Québec, QC, Canada
| | - Kossi Thomas Golo
- Ministère de la santé et des services sociaux (MSSS), 1075, chemin Sainte-Foy, Québec City, QC, Canada
| | - Nizar Ghali
- Ministère de la santé et des services sociaux (MSSS), 1075, chemin Sainte-Foy, Québec City, QC, Canada
| | - Maude Laberge
- Department of Social and Preventive Medicine, Faculty of Medicine, Université Laval, Ferdinand Vandry Pavillon, 1050 Av. de la Médecine, Québec City, QC, Canada; Vitam, Centre de recherche en santé durable-Université Laval, Québec, QC, Canada; Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada
| | - Patricia Li
- Division of General Pediatrics, Department of Pediatrics, McGill University Health Centre - Montreal Children's Hospital, 1001 Decarie Blvd, Montreal, QC, Canada
| | - Marc Beltempo
- Division of Neonatology, Department of Pediatrics, McGill University Health Centre - Montreal Children's Hospital, 1001 Decarie Blvd, Montreal, Quebec, Canada
| | - Guy Lacroix
- Department of Economics, Université Laval, Pavillon Charles-De Koninck, 1030 Av. des Sciences Humaines, Québec, QC, Canada
| | - Hussein Wissanji
- Harvey E. Beardmore Division of Pediatric Surgery, Department of Pediatric Surgery, McGill University Health Center, Montreal Children's Hospital, Canada.
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Brindle ME. Influences on the timing of pediatric umbilical hernia repair in the era of choosing wisely. Surgery 2023; 174:1290-1291. [PMID: 37696724 DOI: 10.1016/j.surg.2023.08.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 08/08/2023] [Indexed: 09/13/2023]
Affiliation(s)
- Mary E Brindle
- Cumming School of Medicine University of Calgary, Pediatric General Surgeon, Alberta Children's Hospital, Calgary, Alberta, Canada; Director of Safe Surgery Systems at Ariadne Labs, Brigham and Women's Hospital, Harvard TH Chan School of Public Health, Boston, MA.
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Benítez TM, Kim YJ, Kong L, Wang L, Chung KC. Impact of consensus guideline publication on the timing of elective pediatric umbilical hernia repair. Surgery 2023; 174:1281-1289. [PMID: 37586892 DOI: 10.1016/j.surg.2023.07.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 07/10/2023] [Accepted: 07/18/2023] [Indexed: 08/18/2023]
Abstract
BACKGROUND The American Academy of Pediatrics published consensus guidelines advising observation of asymptomatic umbilical hernias until age 4 or 5, given unnecessary risks of early intervention and substantial practice variation. Yet, the impact of guidelines on early repair (age <4) or if certain groups remain at risk for avoidable intervention is unclear. METHODS This retrospective study used data from children's hospitals participating in the Pediatric Health Information System database. Children aged 17 years and younger who underwent umbilical hernia repair from July 2017 to August 2022 were eligible for inclusion. Children with recurrent hernias, an emergency, or urgent presentation were excluded. An interrupted time series using segmented multivariable logistic regression estimated the association of guideline publication in November 2019 with the odds of guideline-adherent repair (age ≥4) after adjusting for sociodemographic characteristics and hospital-level random effects. RESULTS 16,544 children underwent repair, of which 3,115 (18.8%) were children <4 years old. After adjustment, guideline publication was associated with an immediate increase in guideline-adherent repairs (odds ratio = 1.25 95% confidence interval = 1.05-1.49). The interrupted time series found that each month after publication was associated with a 2% increase in the odds of guideline-adherent repair (odds ratio = 1.02, 95% confidence interval = 1.01-1.03). Children with public insurance were nearly 20% less likely to receive guideline-adherent repair than privately insured children (odds ratio = 0.82, 95% confidence interval = 0.74-0.91). Children in the Midwest had lower odds of guideline-adherent repair (Midwest versus Northeast: odds ratio = 0.45. 95% confidence interval = 0.24-0.84). CONCLUSION Guideline publication was associated with greater odds of guideline-adherent repair, yet public insurance coverage and Midwest location remain significant predictors of early repair against recommendations.
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Affiliation(s)
- Trista M Benítez
- University of Michigan Medical School, Ann Arbor, MI; Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor, MI. https://www.twitter.com/benitez_trista
| | - You J Kim
- Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor, MI; Rush University Medical College, Chicago, IL. https://www.twitter.com/kim_youj
| | - Lingxuan Kong
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, MI
| | - Lu Wang
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, MI
| | - Kevin C Chung
- Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor, MI.
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Broomfield M, Agabani Z, Guadagno E, Poenaru D, Baird R. The evidence mismatch in pediatric surgical practice. Pediatr Surg Int 2023; 39:295. [PMID: 37978994 DOI: 10.1007/s00383-023-05569-w] [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] [Accepted: 10/15/2023] [Indexed: 11/19/2023]
Abstract
PURPOSE Outpatient pediatric surgical practice often involves conditions of limited morbidity but significant parental concern. We explore existing evidence-based management recommendations and the mismatch with practice patterns for four common outpatient pediatric surgical conditions. METHODS Using the Cochrane Rapid Review Group recommendations and librarian oversight, we conducted a rapid review of four outpatient surgical conditions: dermoid cysts, epigastric hernias, hydroceles, and umbilical hernias. We extracted patient demographics, intervention details, outcome measures and evaluated justifications presented for chosen management options. A metric of evidence volume (patient/publication ratio) was generated and compared between diagnoses. RESULTS Out of 831 articles published since 1990, we identified 49 cohort studies (10-dermoid cyst, 6-epigastric hernia, 25-hydrocele, and 8-umbilical hernia). The 49 publications included 34,172 patients treated across 18 countries. The evidence volume for each outpatient condition demonstrates < 1 cohort/condition/year. The evidence mismatch rate varied between 33 and 75%; many existing recommendations are not evidence-based, sometimes conflicting and frequently misrepresentative of clinical practice. CONCLUSIONS Published literature concerning common outpatient pediatric surgical conditions is sparse and demonstrates wide variations in practice. All individual practice choices were justified using either risk of complications or patient preference. Most early intervention practices were based on weak or outdated studies and "common wisdom" rather than genuine evidence. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Marina Broomfield
- Harvey E. Beardmore Division of Pediatric Surgery, The Montreal Children's Hospital, McGill University Health Center, Montreal, QC, Canada
- Faculty of Medicine and Health Sciences, McGill University, Montreal, QC, Canada
| | - Zena Agabani
- Harvey E. Beardmore Division of Pediatric Surgery, The Montreal Children's Hospital, McGill University Health Center, Montreal, QC, Canada
- University of Toronto, Toronto, ON, Canada
| | - Elena Guadagno
- Harvey E. Beardmore Division of Pediatric Surgery, The Montreal Children's Hospital, McGill University Health Center, Montreal, QC, Canada
| | - Dan Poenaru
- Harvey E. Beardmore Division of Pediatric Surgery, The Montreal Children's Hospital, McGill University Health Center, Montreal, QC, Canada
- Faculty of Medicine and Health Sciences, McGill University, Montreal, QC, Canada
| | - Robert Baird
- Division of Pediatric Surgery, BC Children's Hospital, 4480 Oak Street, Vancouver, Canada.
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Ngom G, Zeng FTA, Sagna A, Gueye D, Ndoye NA, Mbaye PA, Ndiaye C, Fall M, Ndour O. Management of Umbilical Hernia in African Children: The Experience of 2146 Cases. J Indian Assoc Pediatr Surg 2023; 28:212-217. [PMID: 37389397 PMCID: PMC10305955 DOI: 10.4103/jiaps.jiaps_115_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 01/03/2023] [Accepted: 01/10/2023] [Indexed: 07/01/2023] Open
Abstract
Aims Umbilical hernia (UH) is common in African and African-descent children. In high-income countries (HICs), it is considered benign, which is not the case in Sub-Saharan ones. Through this study, we aimed to share our experience. Materials and Methods A descriptive review was conducted from January 01, 2012 to December 31, 2017 at Albert Royer National Children's Hospital Center. Among the 2499 patients, 2146 cases were included in the review. Results UH had a frequency of 6.5%, with patients having a mean age of 2.6 years, with a male preponderance of 63%. Emergency consultation occurred in 37.1%. The symptomatic hernia was present in 90.9%. The congenital type was found in 96%, a history of painful episodes was reported in 46%, and medical and surgical comorbidities were found in 30.1% and 16.4%, respectively. Multimodal anesthesia was used in 93.1%. A lower umbilical crease incision was made in 83.2%, the sac was not empty in 16.3%, and additional umbilicoplasty was performed in 16.3%. During a 14-month follow-up, a complication occurred in 6.5% and mortality in 0.05%. Conclusion In our region, the pediatric UH was predominantly symptomatic, with its natural evolution leading to more complications than in HICs. Its management carried acceptable morbidity.
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Affiliation(s)
- Gabriel Ngom
- Department of Pediatric Surgery, Albert Royer National Children's Hospital Center, Cheikh Anta Diop University, Dakar, Senegal
| | - Florent Tshibwid A. Zeng
- Department of Pediatric Surgery, Albert Royer National Children's Hospital Center, Cheikh Anta Diop University, Dakar, Senegal
| | - Aloise Sagna
- Department of Pediatric Surgery, Albert Royer National Children's Hospital Center, Cheikh Anta Diop University, Dakar, Senegal
| | - Doudou Gueye
- Department of Pediatric Surgery, Albert Royer National Children's Hospital Center, Cheikh Anta Diop University, Dakar, Senegal
| | - Ndeye Aby Ndoye
- Department of Pediatric Surgery, Albert Royer National Children's Hospital Center, Cheikh Anta Diop University, Dakar, Senegal
| | - Papa Alassane Mbaye
- Department of Pediatric Surgery, Albert Royer National Children's Hospital Center, Cheikh Anta Diop University, Dakar, Senegal
| | - Cheikh Ndiaye
- Department of Pediatric Surgery, Albert Royer National Children's Hospital Center, Cheikh Anta Diop University, Dakar, Senegal
| | - Mbaye Fall
- Department of Pediatric Surgery, Aristide Le Dantec University Teaching Hospital, Cheikh Anta Diop University, Dakar, Senegal
| | - Oumar Ndour
- Department of Pediatric Surgery, Aristide Le Dantec University Teaching Hospital, Cheikh Anta Diop University, Dakar, Senegal
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7
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Doty ME, Gil LA, Cooper JN. Association between high deductible health plan coverage and age at pediatric umbilical hernia repair. WORLD JOURNAL OF PEDIATRIC SURGERY 2023; 6:e000526. [PMID: 36969906 PMCID: PMC10030914 DOI: 10.1136/wjps-2022-000526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 02/20/2023] [Indexed: 03/29/2023] Open
Abstract
Background High deductible health plans (HDHPs) are associated with the avoidance of both necessary and unnecessary healthcare. Umbilical hernia repair (UHR) is a procedure that is frequently unnecessarily performed in young children, contrary to best practice guidelines. We hypothesized that children with HDHPs, as compared with other types of commercial health plans, are less likely to undergo UHR before 4 years of age but are also more likely to have UHR delayed beyond 5 years of age. Methods Children aged 0-18 years old residing in metropolitan statistical areas (MSAs) who underwent UHR in 2012-2019 were identified in the IBM Marketscan Commercial Claims and Encounters Database. A quasi-experimental study design using MSA/year-level HDHP prevalence among children as an instrumental variable was employed to account for selection bias in HDHP enrollment. Two-stage least squares regression modeling was used to evaluate the association between HDHP coverage and age at UHR. Results A total of 8601 children were included (median age 5 years, IQR 3-7). Univariable analysis revealed no differences between the HDHP and non-HDHP groups in the likelihood of UHR being performed before 4 years of age (27.7% vs 28.7%, p=0.37) or after 5 years of age (39.8% vs 38.9%, p=0.52). Geographical region, metropolitan area size, and year were associated with HDHP enrollment. Instrumental variable analysis demonstrated no association between HDHP coverage and undergoing UHR at <4 years of age (p=0.76) or >5 years of age (p=0.87). Conclusions HDHP coverage is not associated with age at pediatric UHR. Future studies should investigate other means by which UHRs in young children can be avoided.
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Affiliation(s)
- Morgan E Doty
- The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Lindsay A Gil
- Department of Surgery, Nationwide Children’s Hospital, The Ohio State University, Columbus, Ohio, USA
| | - Jennifer N Cooper
- Department of Pediatrics, Nationwide Children’s Hospital, The Ohio State University, Columbus, Ohio, USA
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Khorami AK, Oliveira CB, Maher CG, Bindels PJE, Machado GC, Pinto RZ, Koes BW, Chiarotto A. Recommendations for Diagnosis and Treatment of Lumbosacral Radicular Pain: A Systematic Review of Clinical Practice Guidelines. J Clin Med 2021; 10:jcm10112482. [PMID: 34205193 PMCID: PMC8200038 DOI: 10.3390/jcm10112482] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 05/27/2021] [Accepted: 05/28/2021] [Indexed: 12/29/2022] Open
Abstract
The management of patients with lumbosacral radicular pain (LRP) is of primary importance to healthcare professionals. This study aimed to: identify international clinical practice guidelines on LRP, assess their methodological quality, and summarize their diagnostic and therapeutic recommendations. A systematic search was performed (August 2019) in MEDLINE, PEDro, National Guideline Clearinghouse, National Institute for Health and Clinical Excellence (NICE), New Zealand Guidelines Group (NZGG), International Guideline Library, Guideline central, and Google Scholar. Guidelines presenting recommendations on diagnosis and/or treatment of adult patients with LRP were included. Two independent reviewers selected eligible guidelines, evaluated quality with Appraisal of Guidelines Research & Evaluation (AGREE) II, and extracted recommendations. Recommendations were classified into 'should do', 'could do', 'do not do', or 'uncertain'; their consistency was labelled as 'consistent', 'common', or 'inconsistent'. Twenty-three guidelines of varying quality (AGREE II overall assessment ranging from 17% to 92%) were included. Consistent recommendations regarding diagnosis are ('should do'): Straight leg raise (SLR) test, crossed SLR test, mapping pain distribution, gait assessment, congruence of signs and symptoms. Routine use of imaging is consistently not recommended. The following therapeutic options are consistently recommended ('should do'): educational care, physical activity, discectomy under specific circumstances (e.g., failure of conservative treatment). Referral to a specialist is recommended when conservative therapy fails or when steppage gait is present. These recommendations provide a clear overview of the management options in patients with LRP.
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Affiliation(s)
- Ahmad Khoshal Khorami
- Department of General Practice, Erasmus MC, University Medical Center Rotterdam, 3000 CA Rotterdam, The Netherlands; (A.K.K.); (P.J.E.B.); (B.W.K.)
| | - Crystian B. Oliveira
- Physical Therapy Department, Faculty of Medicine, University of Western São Paulo (UNOESTE), Presidente Prudente, Sao Paulo CEP 19060-900, Brazil;
- Institute for Musculoskeletal Health, Sydney Local Health District, Sydney, NSW 2050, Australia; (C.G.M.); (G.C.M.)
| | - Christopher G. Maher
- Institute for Musculoskeletal Health, Sydney Local Health District, Sydney, NSW 2050, Australia; (C.G.M.); (G.C.M.)
- Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, NSW 2050, Australia
| | - Patrick J. E. Bindels
- Department of General Practice, Erasmus MC, University Medical Center Rotterdam, 3000 CA Rotterdam, The Netherlands; (A.K.K.); (P.J.E.B.); (B.W.K.)
| | - Gustavo C. Machado
- Institute for Musculoskeletal Health, Sydney Local Health District, Sydney, NSW 2050, Australia; (C.G.M.); (G.C.M.)
- Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, NSW 2050, Australia
| | - Rafael Z. Pinto
- Department of Physical Therapy, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte 30000-000, Brazil;
| | - Bart W. Koes
- Department of General Practice, Erasmus MC, University Medical Center Rotterdam, 3000 CA Rotterdam, The Netherlands; (A.K.K.); (P.J.E.B.); (B.W.K.)
- Center for Muscle and Joint Health, University of Southern Denmark, 5230 Odense, Denmark
| | - Alessandro Chiarotto
- Department of General Practice, Erasmus MC, University Medical Center Rotterdam, 3000 CA Rotterdam, The Netherlands; (A.K.K.); (P.J.E.B.); (B.W.K.)
- Correspondence: ; Tel.: +31-1-0704-1038
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Villamil V, Vallejo OG, Morote JMS, Bermejo JPH. Giant umbilical hernia: "Lazy M-Omega" flap, a case report. Pan Afr Med J 2021; 38:338. [PMID: 34285760 PMCID: PMC8265248 DOI: 10.11604/pamj.2021.38.338.23255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Accepted: 05/10/2020] [Indexed: 11/11/2022] Open
Abstract
Umbilical hernia, one of the most frequent pathologies in pediatric surgical practice, is usually corrected with a relatively simple intervention, except in cases where there is a major defect, also called proboscoid hernia. We present a case report of a 20-month male patient that underwent surgical intervention of a giant umbilical hernia with the "Lazy-M and Omega" flap novel surgical technique. This technique has to be taken into account in surgical planning, since it is simple and easily reproducible.
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Affiliation(s)
- Vanesa Villamil
- Pediatric Surgery Service, Sant Joan de Déu Children's Hospital, Barcelona, Spain
| | - Oscar Girón Vallejo
- Pediatric Surgery Service, University Clinical Hospital Virgen de la Arrixaca, Murcia, Spain
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Shinkunas LA, Klipowicz CJ, Carlisle EM. Inappropriate referrals in pediatric surgery. J Pediatr Surg 2020; 55:2596-2601. [PMID: 32660777 DOI: 10.1016/j.jpedsurg.2020.06.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Revised: 05/29/2020] [Accepted: 06/09/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Inappropriate referrals consume a significant amount of health-system resources. To optimize referral patterns, organizations such as the American Academy of Pediatrics provide policy statements regarding appropriate surgical referrals. Here, we identify the volume/characteristics of inappropriate referrals to pediatric surgeons. METHODS Retrospective chart review of new patients evaluated in the Pediatric Surgery Clinic at a university-based, tertiary-care Children's Hospital over 12-months. Demographics, insurance, referring provider/surgeon diagnosis, and referring provider specialty were abstracted and coded as appropriate/inappropriate. RESULTS Five hundred nine referrals were identified; 19% were inappropriate. Inappropriate referrals were more common from mid-level providers (OR = 1.97, p = 0.02) and non-pediatric providers (OR = 1.94, p = 0.01) compared to physicians and pediatric providers. Female patients (OR = 1.65, p = 0.03) and younger patients (OR = 0.94, p = 0.002) were more likely to have an inappropriate referral than their older, male peers. Umbilical hernia, chest wall deformity, and GI complaint were the diagnoses most frequently given to inappropriately referred patients. Average distance traveled by patients for an inappropriate referral was 57.8 miles with significant difference in average distance traveled for rural (78 miles; range = 12-199) and urban (42 miles; range = 0-125) patients (p < 0.01). CONCLUSIONS Despite guidelines on appropriate referral patterns, 19% of pediatric surgery referrals are inappropriate. Increased supervision of mid-level providers, training in pediatrics, or referral to a local pediatrician prior to surgical consultation may decrease the rate of inappropriate referrals. TYPE OF STUDY Prognosis. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Laura A Shinkunas
- University of Iowa Carver College of Medicine, Program in Bioethics and Humanities, Iowa City, IA, USA
| | | | - Erica M Carlisle
- University of Iowa Hospitals and Clinics, Department of Surgery, Iowa City, IA, USA.
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11
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Kohler JE, Cartmill RS, Yang DY, Fernandes-Taylor S, Greenberg CC. Age-Dependent Costs and Complications in Pediatric Umbilical Hernia Repair. J Pediatr 2020; 226:236-239. [PMID: 32629008 DOI: 10.1016/j.jpeds.2020.07.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 06/08/2020] [Accepted: 07/01/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To characterize regional variation in the age of patients undergoing umbilical hernia repair to determine costs and subsequent care. STUDY DESIGN We performed a cross-sectional descriptive study using a large convenience sample of US employer-based insurance claims from July 2012 to December 2015. We identified children younger than 18 years of age undergoing uncomplicated (not strangulated, incarcerated, or gangrenous) umbilical hernia repair as an isolated procedure (International Classification of Diseases, Ninth Revision procedure codes 53.41, 53.42, 53.43, or 53.49, International Classification of Diseases, Tenth Revision procedure code 0WQF0ZZ, or Current Procedural Terminology procedure codes 49580 or 49585). RESULTS In all, 5212 children met criteria for inclusion. Children younger than age 2 years accounted for 9.7% of repairs, with significant variation by census region (6% to 14%, P < .001). Total payments for surgery varied by age; children younger than 2 years averaged $8219 and payments for older children were $6137. Postoperative admissions occurred at a rate of 73.1 per 1000 for children younger than age 2 years and 7.43 for older children; emergency department visits were 41.5 per 1000 for children younger than age 2 years vs 15.9 for older children (P < .001). CONCLUSIONS Umbilical hernias continue to be repaired at early ages with large regional variation. Umbilical hernia repair younger than age 2 years is associated with greater costs and greater frequency of postoperative hospitalization and emergency department visits.
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Affiliation(s)
- Jonathan E Kohler
- Wisconsin Surgical Outcomes Research Program, University of Wisconsin - Madison, Madison, WI; Department of Surgery, University of Wisconsin - Madison, Madison, WI
| | - Randi S Cartmill
- Wisconsin Surgical Outcomes Research Program, University of Wisconsin - Madison, Madison, WI; Department of Surgery, University of Wisconsin - Madison, Madison, WI
| | - Dou-Yan Yang
- Department of Surgery, University of Wisconsin - Madison, Madison, WI
| | - Sara Fernandes-Taylor
- Wisconsin Surgical Outcomes Research Program, University of Wisconsin - Madison, Madison, WI; Department of Surgery, University of Wisconsin - Madison, Madison, WI
| | - Caprice C Greenberg
- Wisconsin Surgical Outcomes Research Program, University of Wisconsin - Madison, Madison, WI; Department of Surgery, University of Wisconsin - Madison, Madison, WI
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12
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Contemporary practice and perceptions surrounding the management of asymptomatic umbilical hernias in children: A survey of the American Pediatric Surgical Association. J Pediatr Surg 2020; 55:2052-2057. [PMID: 32122639 DOI: 10.1016/j.jpedsurg.2020.02.002] [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: 02/01/2020] [Accepted: 02/06/2020] [Indexed: 11/21/2022]
Abstract
PURPOSE To explore variation in perceptions regarding the natural history of asymptomatic umbilical hernias, and to characterize the influence of clinical and nonclinical factors on decision-making surrounding timing of repair. METHODS This was a survey of the American Pediatric Surgical Association. Branching logic and Likert scale questions were used to explore perceptions surrounding natural history (risk of complications and likelihood of spontaneous closure), preferred age for repair, and influence of anatomic, caregiver, sociodemographic, and biological factors on operative timing. RESULTS 44% of members completed the survey (371/846). The most common age respondents would consider elective repair was 3 years (37%), although the majority preferred to wait until 4 or 5 years (54%). Most respondents estimated a <1% risk of complications for unrepaired defects, and much greater variability was found in the perceived likelihood of spontaneous closure over time. Decision-making surrounding operative timing was most influenced by anatomic factors (larger defects, proboscoid changes, and interval growth) and parental anxiety surrounding need for emergency surgery, cosmesis, and stigma of parental neglect. CONCLUSION Practice and perceptions surrounding management of asymptomatic umbilical hernias vary widely. More robust epidemiological data are needed to define the likelihood of spontaneous closure in the context of age and physical exam findings. Collaborative efforts between surgeons and referring providers are also needed to optimize management of caregiver anxiety and expectations surrounding need for surgical referral and repair. LEVEL OF EVIDENCE Level V (expert opinion).
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Hills-Dunlap JL, Melvin P, Graham DA, Anandalwar SP, Kashtan MA, Rangel SJ. Variation in surgical management of asymptomatic umbilical hernia at freestanding children's hospitals. J Pediatr Surg 2020; 55:1324-1329. [PMID: 31255325 DOI: 10.1016/j.jpedsurg.2019.06.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 06/01/2019] [Accepted: 06/08/2019] [Indexed: 11/29/2022]
Abstract
PURPOSE To examine hospital-level variation in the timing of asymptomatic umbilical hernia repair in children. METHODS Retrospective analysis of children undergoing umbilical hernia repair at 38 children's hospitals using the Pediatric Health Information System database (01/2013-12/2017). Early repair was defined as surgery performed at 3 years of age or younger. Repairs were categorized as emergent/urgent if associated with diagnostic or procedural codes indicating obstruction or strangulation, or if they occurred within 2 weeks of an emergency department encounter. Multivariable regression was used to calculate hospital-level observed-to-expected (O/E) ratios for early repair adjusting for emergent/urgent repair and patient characteristics. RESULTS 23,144 children were included, of which 30% underwent early repair (hospital range: 6.9%-54.3%, p ≪ 0.001). Overall, 3.8% of all repairs were emergent/urgent, and higher rates of early repair did not correlate with higher rates of emergent/urgent repair across hospitals (r = -0.10). Following adjustment, hospital-level O/E ratios for early repair varied 8.9-fold (0.19-1.70, p ≪ 0.001). CONCLUSION Timing of asymptomatic umbilical hernia repair varies widely across children's hospitals, and the magnitude of this variation cannot be explained by differences in patient characteristics or the acuity of repair. Many children may be undergoing repair of hernias that may spontaneously close with further observation. LEVEL OF EVIDENCE Level III (retrospective comparative study).
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Affiliation(s)
- Jonathan L Hills-Dunlap
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA; Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| | - Patrice Melvin
- Center for Applied Pediatric Quality Analytics, Boston Children's Hospital, Boston, MA, USA.
| | - Dionne A Graham
- Center for Applied Pediatric Quality Analytics, Boston Children's Hospital, Boston, MA, USA.
| | - Seema P Anandalwar
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.
| | - Mark A Kashtan
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.
| | - Shawn J Rangel
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.
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Halleran DR, Minneci PC, Cooper JN. Association between Age and Umbilical Hernia Repair Outcomes in Children: A Multistate Population-Based Cohort Study. J Pediatr 2020; 217:125-130.e4. [PMID: 31711762 DOI: 10.1016/j.jpeds.2019.10.035] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 09/17/2019] [Accepted: 10/11/2019] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To evaluate whether patient age or other sociodemographic and clinical characteristics are associated with recurrence or unplanned related hospital revisits after pediatric umbilical hernia repair. STUDY DESIGN We performed a retrospective cohort study using the Healthcare Cost and Utilization Project State Inpatient, Emergency Department, and Ambulatory Surgery and Services Databases of 7 states. Pediatric umbilical hernia repairs performed at any hospital or surgery center in 2010-2014 were included. Hernia recurrences and occurrences of unplanned and related hospital revisits within 30 days were evaluated. RESULTS Of 9809 included patients, 52.0% were female and 50.5% were black. The 3-year hernia recurrence rate was 0.57% (95% CI 0.42, 0.73). In multivariable analysis, the recurrence rate was higher in children <4 years of age than in children 4-10 years of age (hazard ratio [HR] 1.93, 95% CI 1.09, 3.44). Unplanned related hospital revisits within 30 days occurred in 2.5% of patients. Patient characteristics associated with the risk of an unplanned related hospital revisit included age <4 years (HR 2.17, 95% CI 1.70, 2.77) or >10 years (HR 2.11, 95% CI 1.46, 3.05), public insurance (HR 2.10, 95% CI 1.58, 2.79), asthma (HR 1.74, 95% CI 1.32, 2.29), and initial presentation to the emergency department (HR 2.46, 95% CI 1.08, 5.61). CONCLUSIONS Rates of recurrence and unplanned related hospital revisits following pediatric umbilical hernia repair are higher in children younger than 4 years of age. These findings support delaying the repair of asymptomatic umbilical hernia in children until 4 years of age.
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Affiliation(s)
- Devin R Halleran
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH; Department of Surgery, Nationwide Children's Hospital, Columbus, OH
| | - Peter C Minneci
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH; Department of Surgery, Nationwide Children's Hospital, Columbus, OH; Department of Surgery, College of Medicine, The Ohio State University, Columbus, OH
| | - Jennifer N Cooper
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH; Department of Pediatrics, College of Medicine, The Ohio State University, Columbus, OH; Division of Epidemiology, College of Public Health, The Ohio State University, Columbus, OH.
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