Outcomes research in pediatric surgery. Part 2: how to structure a research question

"Minimally invasive research?" Use of the electronic health record to facilitate research in pediatric urology

BACKGROUND

The electronic health record (EHR) was designed as a clinical and administrative tool to improve clinical patient care. Electronic healthcare systems have been successfully adopted across the world through use of government mandates and incentives.

METHODS

Using electronic health record, health information system, electronic medical record, health information systems, research, outcomes, pediatric, surgery, and urology as initial search terms, the literature focusing on clinical documentation data capture and the EHR as a potential resource for research related to clinical outcomes, quality improvement, and comparative effectiveness was reviewed. Relevant articles were supplemented by secondary review of article references as well as seminal articles in the field as identified by the senior author.

FINDINGS

US federal funding agencies, including the Agency for Healthcare Research and Quality, the Patient-Centered Outcomes Research Institute, the National Institutes of Health, and the Food and Drug Administration have recognized the EHR's role supporting research. The main approached to using EHR data include enhanced lists, direct data extraction, structured data entry, and unstructured data entry. The EHR's potential to facilitate research, overcoming cost and time burdens associated with traditional data collection, has not resulted in widespread use of EHR-based research tools.

CONCLUSION

There are strengths and weaknesses for all existing methodologies of using EHR data to support research. Collaboration is needed to identify the method that best suits the institution for incorporation of research-oriented data collection into routine pediatric urologic clinical practice.

Extracting autism spectrum disorder data from the electronic health record

BACKGROUND

Little is known about the health care utilization patterns of individuals with pediatric autism spectrum disorder (ASD).

OBJECTIVES

Electronic health record (EHR) data provide an opportunity to study medical utilization and track outcomes among children with ASD.  Methods: Using a pediatric, tertiary, academic hospital's Epic EHR, search queries were built to identify individuals aged 2-18 with International Classification of Diseases, Ninth Revision (ICD-9) codes, 299.00, 299.10, and 299.80 in their records. Codes were entered in the EHR using four different workflows: (1) during an ambulatory visit, (2) abstracted by Health Information Management (HIM) for an encounter, (3) recorded on the patient problem list, or (4) added as a chief complaint during an Emergency Department visit. Once individuals were identified, demographics, scheduling, procedures, and prescribed medications were extracted for all patient-related encounters for the period October 2010 through September 2012.

RESULTS

There were 100,000 encounters for more than 4,800 unique individuals. Individuals were most frequently identified with an HIM abstracted code (82.6%) and least likely to be identified by a chief complaint (45.8%). Categorical frequency for reported race (2 = 816.5, p < 0.001); payor type (2 = 354.1, p < 0.001); encounter type (2 = 1497.0, p < 0.001); and department (2 = 3722.8, p < 0.001) differed by search query. Challenges encountered included, locating available discrete data elements and missing data.

CONCLUSIONS

This study identifies challenges inherent in designing inclusive algorithms for identifying individuals with ASD and demonstrates the utility of employing multiple extractions to improve the completeness and quality of EHR data when conducting research.

Laryngotracheal stenosis and airway surgery--an outcomes based approach

OBJECTIVES

To review the outcomes of endoscopic, open or a combination of both surgical modalities for laryngotracheal stenosis and establish which factors influence results.

METHODS

Records of all children undergoing laryngotracheal procedures (excluding laryngomalacia and aspirated foreign bodies) by the Department of Otolaryngology at The Children's Hospital at Westmead between January 2003 and November 2011 were reviewed. Specific data on population, intervention, covariates and outcomes were recorded and analysed.

RESULTS

A total of 104 patients undergoing 277 procedures were included. 211 (76%) of the procedures were endoscopic, remaining 66 (24%) open. Patients undergoing open surgery were more likely to have significant co-morbidity, prior intubation, require ICU admission or tracheostomy and have a longer hospital stay. 57 (54.8%) patients were successfully treated with a single procedure (48 endoscopic and 9 open). Of the endoscopic patients requiring further surgery, 16 were managed with multiple endoscopic procedures, whilst 12 underwent subsequent open procedures. Open surgery was performed on 66 patients, 63.6% (42/66) of all open procedures required further endoscopic intervention and 45.2% (19/42) of these avoided further open surgery.

CONCLUSIONS

Both open and endoscopic surgery have a role in laryngotracheal stenosis, and many patients benefit from a combination of both. Ultimately the decision depends on experience of the treating team, social considerations, and institutional capabilities. A multi-centre prospective data collection would be a useful tool to further investigate optimal management approach.

Characteristics of hospitals with lowest costs in management of pediatric appendicitis

BACKGROUND

A primary determinant of value in treating appendicitis is inpatient cost. The purpose of this study was to identify hospital-level factors that drive costs associated with the treatment of appendicitis.

METHODS

Cost-to-charge ratios from the 2009 Kids' Inpatient Database gave average all-payer costs by hospital for uncomplicated appendicitis (without peritonitis, ICD-9-CM 540.9) and complicated appendicitis (generalized peritonitis, 540.0; peritoneal abscess, 540.1). The 10% of hospitals with the lowest costs were defined as low cost; the remaining 90% were defined non-low cost. Bivariate and multivariate analyses compared hospital characteristics between the two groups.

RESULTS

Threshold cost dividing low cost from non-low cost for uncomplicated appendicitis was $4626; for complicated appendicitis, it was $6,026. For both conditions teaching status, lower percentage of pediatric discharges, and fewer registered nurses (RN) per 1000 adjusted patient-days predicted a hospital to be low cost. A cost benefit for medium and large hospitals and higher inpatient volume was found only for uncomplicated appendicitis. Regional effects were noted.

CONCLUSIONS

The findings show the high-cost structure of hospitals that care for high volumes of children, emphasizing the need to constrain cost. There is some benefit of economies of scale, and careful attention to the numbers of nursing personnel.