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Johnston W, Mak Croughan A, Hwang R, Myers SR, Davis C, Nace G, Allukian M. Ileocolic Intussusception: Iterative Quality Improvement to Address a Recurring Problem. J Surg Res 2024; 301:623-630. [PMID: 39096551 DOI: 10.1016/j.jss.2024.07.015] [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: 01/17/2024] [Revised: 06/24/2024] [Accepted: 07/06/2024] [Indexed: 08/05/2024]
Abstract
INTRODUCTION Recent quality improvement (QI) initiatives indicate that pediatric patients with uncomplicated ileocolic intussusception can be safely discharged from the emergency department (ED) after fluoroscopic reduction. These programs improve patient experience and reduce cost. We sought to build on these efforts by developing a QI initiative at our own institution that included patients transferred from a satellite campus and focused on iterative improvement of our treatment pathway based on continual reassessment of our processes and data. MATERIALS AND METHODS We formed a multidisciplinary team, established a collaborative open-access clinical pathway, and implemented educational plans for each participating division. Data were tracked prospectively, and process adjustments were made as clinically indicated. In this report, we compare patients treated before and after the QI initiative. RESULTS There were 155 patients treated before the QI initiative (January 1, 2018-June 30, 2022) and 87 after the initiative began (July 1, 2022-October 31, 2023). There were significant improvements in the rate of ED discharge (4/155 (2.6%) versus 51/87 (59%), P < 0.001) and mean time to discharge (40.7 versus 23.1 h, P = 0.002), while the average cost of a visit fell by 30% (P = 0.012). The mean time to discharge from the ED increased (6.9 versus 11.0 h, P < 0.001), and the rate of readmission was unchanged. For patients transferred from the satellite campus, time to fluoroscopic reduction significantly improved during the initiative (9.4 versus 6.5 h, P = 0.048). CONCLUSIONS We implemented a QI program for patients with fluoroscopically reduced ileocolic intussusception that was serially adjusted based on continual reassessment of data. The protocol was associated with a decreased admission rate, total cost, and time to hospital discharge.
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Affiliation(s)
- William Johnston
- Department of General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Allison Mak Croughan
- Department of General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Rosa Hwang
- Department of General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Sage R Myers
- Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Christopher Davis
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Gary Nace
- Department of General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Myron Allukian
- Department of General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.
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Delgado-Miguel C, García A, Delgado B, Muñoz-Serrano AJ, Miguel-Ferrero M, Barrena S, López-Santamaría M, Martínez L. Intussusception Management in Children: A 15-Year Experience in a Referral Center. Indian J Pediatr 2023; 90:1198-1203. [PMID: 35821554 DOI: 10.1007/s12098-022-04248-3] [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: 09/18/2021] [Revised: 02/26/2022] [Accepted: 04/05/2022] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To report a 15-y, single-center experience in the management and outcomes of ileocolic intussusception (ICI) episodes. METHODS A retrospective study was performed in patients with ICI episodes, who were treated at a single quaternary referral center from 2005 to 2019. Data evaluated included patient demographics, clinical presentation, treatment modalities, hospital stay, complications, and outcomes. RESULTS A total of 546 ICI episodes (66.1% males) were included, with a median age at diagnosis of 15 mo. Enema reduction was performed in 478 patients (87.6%), with an overall success rate of 85.8%. Hydrostatic saline enema was the most effective method (89.3%) when compared to pneumatic (80.6%) or barium enema (79.8%), this difference being statistically significant (p = 0.031). No associated complications were observed during nonoperative reduction. Surgical treatment was performed in 101 patients, in whom 36 bowel resections were performed. Postoperative complications were reported in 6 patients (5.9%). Hospital stay was significantly longer in patients with operative management (median 5 d vs. 1 d; p < 0.001). CONCLUSIONS Nonoperative management has a high overall success rate and low complication and recurrence rates. Saline enema reduction presents the highest effectiveness, and should be considered the first-line treatment.
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Affiliation(s)
- Carlos Delgado-Miguel
- Department of Pediatric Surgery, La Paz Children's Hospital, Paseo de la Castellana 261, Madrid, 28046, Spain.
| | - Antonella García
- School of Medicine, Autonomous University of Madrid, Madrid, Spain
| | - Bonifacio Delgado
- Department of Mathematics, Complutense University of Madrid, Madrid, Spain
| | - Antonio J Muñoz-Serrano
- Department of Pediatric Surgery, La Paz Children's Hospital, Paseo de la Castellana 261, Madrid, 28046, Spain
| | - Miriam Miguel-Ferrero
- Department of Pediatric Surgery, La Paz Children's Hospital, Paseo de la Castellana 261, Madrid, 28046, Spain
| | - Saturnino Barrena
- Department of Pediatric Surgery, La Paz Children's Hospital, Paseo de la Castellana 261, Madrid, 28046, Spain
| | - Manuel López-Santamaría
- Department of Pediatric Surgery, La Paz Children's Hospital, Paseo de la Castellana 261, Madrid, 28046, Spain
| | - Leopoldo Martínez
- Department of Pediatric Surgery, La Paz Children's Hospital, Paseo de la Castellana 261, Madrid, 28046, Spain
- Institute for Biomedical Resarch La Paz (IdiPaz), Network for Maternal and Children Health (SAMID), La Paz Children's Hospital, Madrid, Spain
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Attoun MA, Albalawi SMD, Ayoub A, Alnasser AK, Alkaram EH, Khubrani FA, Alzahrani KJ, Alatawi KA, Almutairi N, Alnami AG. The Management of Intussusception: A Systematic Review. Cureus 2023; 15:e49481. [PMID: 38152810 PMCID: PMC10752083 DOI: 10.7759/cureus.49481] [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] [Accepted: 11/27/2023] [Indexed: 12/29/2023] Open
Abstract
Intussusception (ISN) is a dangerous condition where a portion of the intestine slides into an adjacent area of the intestine. This telescoping motion frequently prevents liquids or food from flowing through. Developing management guidelines for ileocolic (IC) intussusception was the aim of this systematic study. Data sources were PubMed/Medical Literature Analysis and Retrieval System Online (MEDLINE), Scopus, and Embase databases. Our review investigated English-language articles (from 2010 to 2023) according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Overall, there were 15 articles. Surveys and analyses of national databases were the most widely used methods (n=15). The search identified 561 studies; 15 were eligible for inclusion in the analysis. Further understanding of the management of intussusception may help improve evaluation and management in the future. The use of preventive antibiotics does not reduce problems following radiologic reduction. When clinically appropriate, repeated attempts at enema reduction may be made. After the enema reduction of ileocolic intussusception, patients can be safely watched in the emergency room (ER), thereby avoiding hospitalization. Success rates for laparoscopic reduction are high. When it comes to intussusception in children who are hemodynamically stable and do not have a serious illness, there is no need for pre-reduction antibiotics. Prioritizing nonoperative outpatient (OP) therapy is recommended as the primary approach, with the utilization of minimally invasive procedures to avoid the necessity for laparotomy. The management of colonic intussusception involves complete removal in one piece, while enteric intussusception can be addressed through reduction followed by resection. A targeted approach is recommended, recognizing the intermediate forms of intussusception that may exist between the colonic and enteric types. It is essential to note that the prevailing treatment for adult intussusception remains to be surgical intervention.
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Affiliation(s)
- Majed Ali Attoun
- Department of Surgery, King Salman Armed Forces Hospital, Tabuk, SAU
| | | | - Afnan Ayoub
- Faculty of Medicine, Batterjee Medical College, Jeddah, SAU
| | - Ali K Alnasser
- Faculty of Medicine, Medical University of Lodz, Lodz, POL
| | - Esraa H Alkaram
- Department of Emergency Medicine, Almana Group of Hospitals (AGH), Dammam, SAU
| | | | - Khalid J Alzahrani
- Department of Radiology, Imam Abdulrahman Bin Faisal University, Dammam, SAU
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Intussusception and COVID-19 in Children: A Systematic Review and Meta-Analysis. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9111745. [PMID: 36421194 PMCID: PMC9688831 DOI: 10.3390/children9111745] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Revised: 10/23/2022] [Accepted: 11/11/2022] [Indexed: 11/16/2022]
Abstract
Background: Intussusception (ISN) post-COVID-19 infection in children is rare but can occur. SARS-CoV-2 may play a role in the pathogenesis of ISN and trigger immune activation and mesenteric adenitis, which predispose peristaltic activity to “telescope” a proximal bowel segment into the distal bowel lumen. Objectives: To estimate the prevalence of SARS-CoV-2 infection in ISN children and analyze the demographic parameters, clinical characteristics and treatment outcomes in ISN pediatric patients with COVID-19 illness. Methods: We performed this systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Studies reporting on the incidence of ISN post-SARS-CoV-2 infection in children, published from 1 December 2019 until 1 October 2022, in PROQUEST, MEDLINE, EMBASE, PUBMED, CINAHL, WILEY ONLINE LIBRARY, SCOPUS and NATURE, with a restriction to articles available in the English language, were included. Results: Of the 169 papers that were identified, 34 articles were included in the systematic review and meta-analysis (28 case report, 5 cohort and 1 case-series studies). Studies involving 64 ISN patients with confirmed COVID-19 (all patients were children) were analyzed. The overall pooled proportions of the ISN patients who had PCR-confirmed SARS-CoV-2 infection was 0.06% (95% CI 0.03 to 0.09, n = 1790, four studies, I2 0%, p = 0.64), while 0.07% (95% CI 0.03 to 0.12, n = 1552, three studies, I2 0%, p = 0.47) had success to ISN pneumatic, hydrostatic and surgical reduction treatment and 0.04% (95% CI 0.00 to 0.09, n = 923, two studies, I2 0%, p = 0.97) had failure to ISN pneumatic, hydrostatic and surgical reduction treatment. The median patient age ranged from 1 to 132 months across studies, and most of the patients were in the 1−12 month age group (n = 32, 50%), p = 0.001. The majority of the patients were male (n = 41, 64.1%, p = 0.000) and belonged to White (Caucasian) (n = 25, 39.1%), Hispanic (n = 13, 20.3%) and Asian (n = 5, 7.8%) ethnicity, p = 0.000. The reported ISN classifications by location were mostly ileocolic (n = 35, 54.7%), and few children experienced ileo-ileal ISN (n = 4, 6.2%), p = 0.001. The most common symptoms from ISN were vomiting (n = 36, 56.2%), abdominal pain (n = 29, 45.3%), red currant jelly stools (n = 25, 39.1%) and blood in stool (n = 15, 23.4%). Half of the patients never had any medical comorbidities (n = 32, 50%), p = 0.036. The approaches and treatments commonly used to manage ISN included surgical reduction of the ISN (n = 17, 26.6%), pneumatic reduction of the ISN (n = 13, 20.2%), antibiotics (n = 12, 18.7%), hydrostatic reduction of the ISN (n = 11, 17.2%), laparotomy (n = 10, 15.6%), intravenous fluids (n = 8, 12.5%) and surgical resection (n = 5, 7.8%), p = 0.051. ISN was recurrent in two cases only (n = 2, 3.1%). The patients experienced failure to pneumatic (n = 7, 10.9%), hydrostatic (n = 6, 9.4%) and surgical (n = 1, 1.5%) ISN treatment, p = 0.002. The odds ratios of death were significantly higher in patients with a female gender (OR 1.13, 95% CI 0.31−0.79, p = 0.045), Asian ethnicity (OR 0.38, 95% CI 0.28−0.48, p < 0.001), failure to pneumatic or surgical ISN reduction treatment (OR 0.11, 95% CI 0.05−0.21, p = 0.036), admission to ICU (OR 0.71, 95% CI 0.83−1.18, p = 0.03), intubation and placement of mechanical ventilation (OR 0.68, 95% CI 0.51−1.41, p = 0.01) or suffering from ARDS (OR 0.88, 95% CI 0.93−1.88, p = 0.01) compared to those who survived. Conclusion: Children with SARS-CoV-2 infection are at low risk to develop ISN. A female gender, Asian ethnicity, failure to ISN reduction treatment (pneumatic or surgical), admission to ICU, mechanical ventilation and suffering from ARDS were significantly associated with death following ISN in pediatric COVID-19 patients.
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Arshad SA, Hebballi NB, Hegde BN, Avritscher EBC, John SD, Lapus RM, Tsao K, Kawaguchi AL. Early discharge after nonoperative management of intussusception is both safe and cost-effective. J Pediatr Surg 2022; 57:147-152. [PMID: 34756701 DOI: 10.1016/j.jpedsurg.2021.09.047] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Accepted: 09/08/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND/PURPOSE We implemented a quality improvement (QI) initiative to safely reduce post-reduction monitoring for pediatric patients with ileocolic intussusception. We hypothesized that there would be decreased length of stay (LOS) and hospital costs, with no change in intussusception recurrence rates. METHODS A retrospective cohort study was conducted of pediatric ileocolic intussusception patients who underwent successful enema reduction at a tertiary-care pediatric hospital from January 2015 through June 2020. In September 2017, an intussusception management protocol was implemented, which allowed discharge within four hours of reduction. Pre- and post-QI outcomes were compared for index encounters and any additional encounter beginning within 24 h of discharge. An economic evaluation was performed with hospital costs inflation-adjusted to 2020 United States Dollars ($). Cost differences between groups were assessed using multivariable regression, adjusting for Medicaid and transfer status, P < 0.05 significant. RESULTS Of 90 patients, 37(41%) were pre-QI and 53(59%) were post-QI. Patients were similar by age, sex, race, insurance status, and transfer status. Pre-QI patients had a median LOS of 23.4 h (IQR: 16.1-34.6) versus 9.3 h (IQR 7.4-14.2) for post-QI patients, P < 0.001. Mean total costs per patient in the pre-QI group were $3,231 (95% CI, $2,442-$4,020) versus $1,861 (95% CI, $1,481-$2,240) in the post-QI group. The mean absolute cost difference was $1,370 less per patient in the post-QI group (95% CI, [-$2,251]-[-$490]). Five patients had an additional encounter within 24 h of discharge [pre-QI: 1 (3%) versus post-QI: 4 (8%), p = 0.7] with four having intussusception recurrence [pre-QI: 1 (3%) versus post-QI: 3 (6%), p = 0.6]. CONCLUSIONS Implementation of a quality improvement initiative for the treatment of pediatric intussusception reduced hospital length of stay and costs without negatively affecting post-discharge encounters or recurrence rates. Similar protocols can easily be adopted at other institutions. LEVEL OF EVIDENCE Level III. TYPE OF STUDY Retrospective comparative treatment study.
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Affiliation(s)
- Seyed A Arshad
- Center for Surgical Trials and Evidence-Based Practice (C-STEP), McGovern Medical School, University of Texas Health Science Center, 6431 Fannin Street, MSB 5.256, Houston, TX 77030, United States; Department of Pediatric Surgery, McGovern Medical School, University of Texas Health Science Center, 6431 Fannin Street, MSB 5.246, Houston, TX 77030, United States; Children's Memorial Hermann Hospital, 6411 Fannin Street, Houston, TX 77030, United States
| | - Nutan B Hebballi
- Center for Surgical Trials and Evidence-Based Practice (C-STEP), McGovern Medical School, University of Texas Health Science Center, 6431 Fannin Street, MSB 5.256, Houston, TX 77030, United States; Children's Memorial Hermann Hospital, 6411 Fannin Street, Houston, TX 77030, United States
| | - Brittany N Hegde
- Center for Surgical Trials and Evidence-Based Practice (C-STEP), McGovern Medical School, University of Texas Health Science Center, 6431 Fannin Street, MSB 5.256, Houston, TX 77030, United States; Department of Pediatric Surgery, McGovern Medical School, University of Texas Health Science Center, 6431 Fannin Street, MSB 5.246, Houston, TX 77030, United States; Children's Memorial Hermann Hospital, 6411 Fannin Street, Houston, TX 77030, United States
| | - Elenir B C Avritscher
- Department of Pediatrics, McGovern Medical School, University of Texas Health Science Center, Houston, United States; Children's Memorial Hermann Hospital, 6411 Fannin Street, Houston, TX 77030, United States
| | - Susan D John
- Department of Diagnostic and Interventional Imaging, McGovern Medical School, University of Texas Health Science Center, Houston, United States; Children's Memorial Hermann Hospital, 6411 Fannin Street, Houston, TX 77030, United States
| | - Robert M Lapus
- Department of Emergency Medicine, McGovern Medical School, University of Texas Health Science Center, Houston, United States; Children's Memorial Hermann Hospital, 6411 Fannin Street, Houston, TX 77030, United States
| | - KuoJen Tsao
- Center for Surgical Trials and Evidence-Based Practice (C-STEP), McGovern Medical School, University of Texas Health Science Center, 6431 Fannin Street, MSB 5.256, Houston, TX 77030, United States; Department of Pediatric Surgery, McGovern Medical School, University of Texas Health Science Center, 6431 Fannin Street, MSB 5.246, Houston, TX 77030, United States; Children's Memorial Hermann Hospital, 6411 Fannin Street, Houston, TX 77030, United States
| | - Akemi L Kawaguchi
- Center for Surgical Trials and Evidence-Based Practice (C-STEP), McGovern Medical School, University of Texas Health Science Center, 6431 Fannin Street, MSB 5.256, Houston, TX 77030, United States; Department of Pediatric Surgery, McGovern Medical School, University of Texas Health Science Center, 6431 Fannin Street, MSB 5.246, Houston, TX 77030, United States; Children's Memorial Hermann Hospital, 6411 Fannin Street, Houston, TX 77030, United States.
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Sarkar A, Ingram MCE, Tian Y, Many BT, Rizeq Y, Goldstein SD, Rigsby CK, Raval MV. A Retrospective Cohort Study of Optimal Contrast for Successful Intussusception Reduction: Institutional Practices Matter. J Surg Res 2021; 267:159-166. [PMID: 34147862 DOI: 10.1016/j.jss.2021.05.020] [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: 01/18/2021] [Revised: 04/20/2021] [Accepted: 05/07/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND The first-line treatment for intussusception is radiologic reduction with either air-contrast enema (AE) or liquid-contrast enema (LE). The purpose of this study was to explore relationships between self-reported institutional AE or LE intussusception reduction preferences and rates of operative intervention and bowel resection. METHODS Pediatric Health Information System (PHIS) hospitals were contacted to assess institutional enema practices for intussusception. A retrospective study using 2009-2018 PHIS data was conducted for patients aged 0-5 y to evaluate outcomes. Chi-squared tests were used to test for differences in the distribution of surgical patients by hospital management approach. RESULTS Of the 45 hospitals, 20 (44%) exclusively used AE, 4 (9%) exclusively used LE, and 21 (46%) used a mixed practice. Of 24,688 patients identified from PHIS, 13,231 (54%) were at exclusive AE/LE hospitals and 11,457 (46%) were at mixed practice hospitals. Patients at AE/LE hospitals underwent operative procedures at lower rates than at mixed practice hospitals (14.8% versus 16.5%, P< 0.001) and were more likely to undergo bowel resection (31.1% versus 27.1%, P= 0.02). CONCLUSIONS Practice variation exists in hospital-level approaches to radiologic reduction of intussusception and mixed practices may impact outcomes.
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Affiliation(s)
- Arjun Sarkar
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Martha-Conley E Ingram
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Yao Tian
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Benjamin T Many
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Yazan Rizeq
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Seth D Goldstein
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Cynthia K Rigsby
- Department of Medical Imaging, Department of Radiology, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - 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, Illinois.
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Delgado-Miguel C, García A, Delgado B, Muñoz-Serrano AJ, Miguel-Ferrero M, Barrena S, Lopez Santamaria M, Martinez L. Routine Ultrasound Control after Successful Intussusception Reduction in Children: Is It Really Necessary? Eur J Pediatr Surg 2021; 31:115-119. [PMID: 33124030 DOI: 10.1055/s-0040-1719055] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Recurrence of ileocolic intussusception (ICI) has been related to residual bowel wall edema after enema reduction. Early oral tolerance has been associated with a higher risk of re-intussusception, so an imaging test (ultrasound) has traditionally been performed before restarting oral tolerance. Our aim is to analyze the cost-effectiveness of performing a routine ultrasound in patients who remain asymptomatic after successful enema reduction. MATERIALS AND METHODS A retrospective observational study was performed in patients with ICI who underwent a successful enema reduction between 2005 and 2019 and distributed in two groups according to whether or not a routine ultrasound was performed before restarting oral tolerance: group A (ultrasound) or B (no ultrasound). We analyzed demographic, clinical and laboratory variables, length of hospital stay, and recurrence rate. RESULTS We included 366 patients who presented 373 ICI episodes (165 in group A and 208 in group B), without significant differences in gender and age. Group A patients presented a higher percentage of vomiting and bloody stools than those in group B without differences in the other clinical features studied, time of evolution, or laboratory variables. Group A presented a higher length of hospital stay than group B (36 vs. 24 hours), although it was not statistically significant (p = 0.30). No statistically significant differences were observed in the recurrence rate between both groups (10.3% A vs. 10.8% B; p = 0.83). CONCLUSION Performing routine ultrasound before restarting oral tolerance in asymptomatic patients after successful ICI reduction does not decrease the risk of re-intussusception and should not be routinely encouraged.
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Affiliation(s)
| | - Antonella García
- Faculty of Medicine, Autonomous University of Madrid, Madrid, Spain
| | - Bonifacio Delgado
- Department of Mathematics, Complutense University of Madrid, Madrid, Comunidad de Madrid, Spain
| | | | | | - Saturnino Barrena
- Department of Pediatric Surgery, Hospital Universitario La Paz, Madrid, Spain
| | | | - Leopoldo Martinez
- Department of Pediatric Surgery, Hospital Universitario La Paz, Madrid, Spain
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Lee EH, Yang HR. Nationwide Population-Based Epidemiologic Study on Childhood Intussusception in South Korea: Emphasis on Treatment and Outcomes. Pediatr Gastroenterol Hepatol Nutr 2020; 23:329-345. [PMID: 32704494 PMCID: PMC7354872 DOI: 10.5223/pghn.2020.23.4.329] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 02/08/2020] [Accepted: 03/06/2020] [Indexed: 01/07/2023] Open
Abstract
PURPOSE This was a nationwide population-based study conducted to investigate the epidemiology, treatment, disease outcomes, and associated factors of childhood intussusception in South Korea. METHODS Data from the Korean National Health Insurance Service database on all patients <18 years old diagnosed with intussusception from 2007 to 2017 were analyzed. RESULTS A total of 34,688 cases were identified among 30,444 patients. The overall incidence was 28.3/100,000 person-years with a male predominance. Most cases (83.1%) occurred in children <3 years old, with an annual incidence of 195.2, 200.1, and 118.6 cases per 100,000 children in their first, second, and third year of life, respectively. The median age at the first occurrence was 18.7 months, and it was higher in boys than in girls. The post-discharge recurrence rate was 10.6% (3,226/30,444) and the in-hospital recurrence rate was 6.1% (1,842/30,444). The total recurrence rate (post-discharge recurrence and/or in-hospital recurrence) was 15.0% (4,580/30,444). Enema reduction was successful in 90.0% of cases. Enema reduction was more successful in girls than in boys. A total of 3,296 (10.8%) patients underwent 3,481 surgeries, including 735 (21.1%) laparoscopic surgeries. Post-discharge recurrence and surgery were significantly affected by age, sex, and hospital type. Mortality was noted in nine cases (0.03%). CONCLUSION Our study provides accurate epidemiologic data on the treatment and outcomes of intussusception through complete enumeration during an 11-year-period.
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Affiliation(s)
- Eun Hye Lee
- Department of Pediatrics, Nowon Eulji Medical Center, Seoul, Korea.,Department of Pediatrics, Eulji University School of Medicine, Daejeon, Korea
| | - Hye Ran Yang
- Department of Pediatrics, Seoul National University Bundang Hospital, Seongnam, Korea.,Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
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9
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Ferrantella A, Quinn K, Parreco J, Quiroz HJ, Willobee BA, Ryon E, Thorson CM, Sola JE, Perez EA. Incidence of recurrent intussusception in young children: A nationwide readmissions analysis. J Pediatr Surg 2020; 55:1023-1025. [PMID: 32247601 DOI: 10.1016/j.jpedsurg.2020.02.034] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Accepted: 02/20/2020] [Indexed: 12/30/2022]
Abstract
BACKGROUND/PURPOSE Recurrent intussusception following successful nonoperative reduction has previously been reported with a frequency of 8%-12% based on data from individual institutions. Meanwhile, the timing of discharge after successful reduction continues to be debated. Here, we evaluate readmissions for recurrent intussusception in young children using a large-scale national database. METHODS The National Readmissions Database (2010-2014) was queried to identify young children (age < 5 years) diagnosed with intussusception. We compared procedures performed during the index admission and frequency of readmissions for recurrent intussusception. Results were weighted for national estimates. RESULTS We identified 8289 children diagnosed with intussusception during an index admission. These patients received definitive treatment with nonoperative reduction alone (43%), surgical reduction (42%), or bowel resection (15%). Readmission for recurrent intussusception was required for 3.7% of patients managed with nonoperative reduction alone, 2.3% of patients that underwent surgical reduction, and 0% of those that underwent bowel resection. Median time to readmission was 4 days after nonoperative reduction, and only 1.5% of these patients experienced recurrence within 48 h of discharge. CONCLUSIONS Recurrent intussusception may be substantially less common than previously reported. Our findings support the practice of discharge shortly after successful nonoperative reduction. TYPE OF STUDY Retrospective, prognosis study. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Anthony Ferrantella
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Kirby Quinn
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Joshua Parreco
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Hallie J Quiroz
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Brent A Willobee
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Emily Ryon
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Chad M Thorson
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Juan E Sola
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Eduardo A Perez
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA.
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The cost of childhood intussusception in Ontario from 2003 to 2016: A population-based study. J Pediatr Surg 2020; 55:883-888. [PMID: 32067807 DOI: 10.1016/j.jpedsurg.2020.01.035] [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: 01/06/2020] [Accepted: 01/25/2020] [Indexed: 11/21/2022]
Abstract
BACKGROUND Management of pediatric intussusception has evolved to favor non-surgical reduction with potential outpatient management. The overall impact of these changes on healthcare costs is unknown. METHODS A retrospective longitudinal cohort study was conducted utilizing population-based universal-access administrative healthcare data to identify patients <18 years treated for intussusception January 2003-December 2016 in Ontario, Canada. Hospital-associated cost included emergency department and cost of hospitalization, while total cost also included billable physician costs. All costs are presented in 2016 Canadian Dollars. RESULTS The median hospital-associated costs for each modality were: non-surgical $2467, failed non-surgical $6508, and surgical only $8863 (p < 0.0001). Costs associated with non-surgical or surgical only management did not change over the study period, whereas costs associated with failed non-surgical management increased from $3842 in 2003 to $12,350 in 2016 (p = 0.0003). Similar trends were observed when physician billing data was included. Costs were $1076.95 higher in community hospitals than academic hospitals (95% CI: $344, $1810; p = 0.004). CONCLUSION The cost of care for intussusception is dependent upon treatment modality and was lowest for non-surgical management and highest for patients treated in community hospitals. Efforts to standardize care to promote successful non-surgical management and to facilitate early discharge could provide cost savings to the healthcare system. TYPE OF STUDY Cost Effectiveness Study. LEVEL OF EVIDENCE IV.
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Vo A, Levin TL, Taragin B, Khine H. Management of Intussusception in the Pediatric Emergency Department: Risk Factors for Recurrence. Pediatr Emerg Care 2020; 36:e185-e188. [PMID: 29232349 DOI: 10.1097/pec.0000000000001382] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The standard treatment for intussusception is air reduction enema (ARE) with inpatient observation for 24 to 48 hours to monitor for recurrence. More recent but limited observations suggest that patients who have undergone successful ARE can safely be discharged after 4 to 6 hours of observation. Our primary objective was to identify risk factors associated with early recurrence. Our secondary objectives included validating risk criteria from prior studies and identifying risk factors for ARE failures. DESIGN/METHODS A retrospective cohort study of children discharged from a large urban quaternary hospital with a final diagnosis of intussusception (International Classification of Diseases, Ninth Revision, code 560.0) or who underwent ARE from 2005 to 2015 was identified. Demographic data, radiology images, and clinical course were recorded. Repeat visits, cases with incomplete medical records, and those with incorrect diagnoses were excluded. RESULTS A total of 250 cases were identified. Two hundred cases were included for analysis. Fifty were excluded. Of the 163 who had successful reduction with ARE, 22 patients (13.5%) recurred, and 12 (7.3%) recurred within 48 hours. Fever (odds ratio, 4.25; P = 0.04; 95% confidence interval, 1.04-17.3) and female sex (odds ratio, 7.94; P = 0.01; 95% confidence interval, 1.82-34.6) were independently associated with early recurrence. No radiologic features were associated with early recurrence. CONCLUSIONS Early recurrence after successful ARE was low, although more frequent in girls and in those with fever over 100.4°F. We therefore advocate for prospective studies to validate these risk criteria to identify patients who are at low risk for early recurrence and may qualify for early discharge from the emergency department.
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Affiliation(s)
| | - Terry L Levin
- Radiology, Albert Einstein College of Medicine, Children's Hospital at Montefiore, Bronx, NY
| | - Benjamin Taragin
- Radiology, Albert Einstein College of Medicine, Children's Hospital at Montefiore, Bronx, NY
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12
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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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Point-of-Care Ultrasound Could Streamline the Emergency Department Workflow of Clinically Nonspecific Intussusception. Pediatr Emerg Care 2020; 36:e90-e95. [PMID: 28926507 DOI: 10.1097/pec.0000000000001283] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVES The aim of this study was to evaluate whether point-of-care ultrasound (POCUS) for intussusception screening streamlines the workflow of clinically nonspecific intussusception (CNI), an intussusception presenting with only 1 manifestation of the classic triad, and/or vomiting. METHODS We reviewed 274 consecutive children with intussusception, aged 6 years or younger, who visited a tertiary care hospital emergency department between May 2012 and April 2016. This period was dichotomized by May 2014 (the "PRE" and "POST" groups), starting point of implementation of the POCUS protocol for intussusception screening. All children with CNI who had positive results on or forwent POCUS underwent radiologist-performed ultrasound (US). We measured and compared emergency department length of stay (EDLOS), the sum of door-to-reduction and observation times, and the frequency of POCUS and positive US results between the 2 groups. RESULTS Of 160 children with CNI, 93 visited the emergency department since May 2014. The POST group showed a shorter median EDLOS (856 vs 630 minutes, P < 0.001), door-to-reduction time (137 vs 111 minutes, P = 0.002), and observation time (700 vs 532 minutes, P < 0.001). The POST group had a higher frequency of POCUS (12% vs 60%, P < 0.001) with positive US results (33% vs 59%, P < 0.001). The PRE group had a higher frequency of severe bowel edema (16% vs 1%, P < 0.001). No significant differences were found in the severity, recurrence, admission, and surgery. One child had a false-negative result on POCUS. CONCLUSIONS Point-of-care ultrasound could streamline the workflow of CNI via decrease in EDLOS and unnecessary referrals for US.
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14
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Development and Implementation of a Surgical Quality Improvement Pathway for Pediatric Intussusception Patients. Pediatr Qual Saf 2019; 4:e205. [PMID: 31745508 PMCID: PMC6805102 DOI: 10.1097/pq9.0000000000000205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Accepted: 07/30/2019] [Indexed: 11/26/2022] Open
Abstract
Children with intussusception can be admitted or discharged from the emergency department (ED) following enema reduction, but little is known about best practices for surgical follow-up and the need for a return to care. Methods We developed a standardized clinical assessment and management plan (SCAMP) for ileocolic intussusception to enable the discharge from the ED of successfully reduced patients meeting certain criteria with 2 planned follow-up phone calls by surgical personnel after discharge. Outcomes included incidence of complications in discharged patients, bacteremia, the success of follow-up phone calls, rates of recurrent intussusception, and return to care. Results Of the 118 patient encounters treated through the SCAMP in 2 pilot studies from February 2013 to December 2017, 76% met discharge criteria, of whom 88% underwent outpatient management. There were no instances of bowel perforation, necrosis, or death in the discharged group. No patients developed bacteremia despite withholding antibiotics for the indication of intussusception. Sixty-two percent and 59% of patients received 24-hour follow-up phone calls, and 28% and 55% of patients received second follow-up phone calls in pilots 1 and 2, respectively. Of those successfully discharged, 74% did not return to care, 19% returned for recurrent intussusception, and 7% returned for unrelated symptoms. Nearly all patients who returned to care did so through the ED and not the clinic. Conclusions Implementation of the SCAMP demonstrated that patients meeting certain criteria could be safely discharged from the ED, avoid antibiotics, and safely undergo phone-based follow-up for concerns of recurrent intussusception.
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Michelson KA, Bachur RG, Mahajan P, Finkelstein JA. Complications of Serious Pediatric Conditions in the Emergency Department: Definitions, Prevalence, and Resource Utilization. J Pediatr 2019; 214:103-112.e3. [PMID: 31383471 DOI: 10.1016/j.jpeds.2019.06.064] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 06/03/2019] [Accepted: 06/25/2019] [Indexed: 12/24/2022]
Abstract
OBJECTIVES To define and measure complications across a broad set of acute pediatric conditions in emergency departments using administrative data, and to assess the validity of these definitions by comparing resource utilization between children with and without complications. STUDY DESIGN Using local consensus, we predefined complications for 16 acute conditions including appendicitis, diabetic ketoacidosis, ovarian torsion, stroke, testicular torsion, and 11 others. We studied patients under age 18 years using 3 data years from the Healthcare Cost and Utilization Project Statewide Databases of Maryland and New York. We measured complications by condition. Resource utilization was compared between patients with and without complications, including hospital length of stay, and charges. RESULTS We analyzed 27 087 emergency department visits for a serious condition. The most common was appendicitis (n = 16 794), with 24.3% of cases complicated by 1 or more of perforation (24.1%), abscess drainage (2.8%), bowel resection (0.3%), or sepsis (0.9%). Sepsis had the highest mortality (5.0%). Children with complications had higher resource utilization: condition-specific length of stay was longer when complications were present, except ovarian and testicular torsion. Hospital charges were higher among children with complications (P < .05) for 15 of 16 conditions, with a difference in medians from $3108 (testicular torsion) to $13 7694 (stroke). CONCLUSIONS Clinically meaningful complications were measurable and were associated with increased resource utilization. Complication rates determined using administrative data may be used to compare outcomes and improve healthcare delivery for children.
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Affiliation(s)
| | - Richard G Bachur
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
| | - Prashant Mahajan
- Department of Emergency Medicine and Pediatrics, University of Michigan Medical School, Ann Arbor, MI
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16
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Abstract
OBJECTIVE To ascertain the degree of variation, by state of acute care hospitalization, in outcomes associated with traumatic brain injury (TBI) in an adult population. SETTING All acute care hospitals in 21 states in the United States in the year 2010. PARTICIPANTS Adult (> 18 years) patients (N = 95 546) admitted to a hospital with a moderate or severe TBI. DESIGN Retrospective cohort study using data from State Inpatient Databases from Agency for Healthcare Research and Quality's Healthcare Cost and Utilization Project. MAIN MEASURES Inpatient mortality and discharge to inpatient rehabilitation. RESULTS The adjusted risk of inpatient mortality varied between states by as much as 40%, with age, severity of injury, and insurance status as significant factors in both outcomes. The adjusted risk of discharge to inpatient rehabilitation varied between by more than 100% among the states measured. CONCLUSIONS There was clinically significant variation between states in inpatient mortality and rehabilitation discharge after adjusting for variables known to affect each outcome. Future efforts should be focused on identifying the causes of this state-to-state variation, how these causes affect patient outcomes, and may serve as a guide to further standardization of treatment for traumatic brain injury across the United States.
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Tessler RA, Graves JM, Vavilala MS, Goldin A, Rivara FP. Hospital factors associated with higher costs in pediatric blunt abdominal trauma: A national study. J Pediatr Surg 2019; 54:1621-1627. [PMID: 30773396 PMCID: PMC7477749 DOI: 10.1016/j.jpedsurg.2018.12.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Revised: 11/14/2018] [Accepted: 12/14/2018] [Indexed: 01/30/2023]
Abstract
BACKGROUND/PURPOSE Our objective was to evaluate hospital factors, including children's hospital status, associated with higher costs for blunt solid organ pediatric abdominal trauma. METHODS We queried the 2012 Healthcare Cost and Utilization Project (HCUP) Kid's Inpatient Database (KID) for patients 18 years or younger with low-grade and high-grade blunt abdominal trauma. We calculated total hospital costs and adjusted cost ratios (CR) controlling for patient and hospital-level characteristics. RESULTS The 2012 KID included 882 low-grade and 222 high-grade pediatric abdominal trauma patients. Median (interquartile range) per hospitalization costs were similar at children's and nonchildren's hospitals for both low-grade (children's = $6575 [$4333-$10,862], nonchildren's $7027 [$4230-$12,219] p = 0.47) and high-grade (children's = $10,984 [$6211- $20,007] nonchildren's $10,156 [$5439-$18,404] p = 0.55) groups. Adjusted cost ratios demonstrated higher costs in the West and among investor owned hospitals for low-grade and high-grade injuries, respectively. Costs at rural hospitals were higher in both groups (low-grade CR = 2.35 95% CI 2.02, 2.74, high-grade CR = 2.78 95% CI 2.13, 3.63) compared to urban teaching hospitals. Cost ratios did not differ based on children's hospital status. CONCLUSION Hospital costs were similar for children's and nonchildren's hospitals caring for pediatric abdominal trauma. Costs at rural hospitals are higher and may suggest financial instability or nonstandardized care of pediatric trauma patients. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Robert A. Tessler
- University of Washington, Harborview Injury Prevention and Research Center, 401 Broadway, 4th floor, Seattle, WA 98122,University of Pittsburgh, Department of Surgery, UPMC Presbyterian Hospital F1281, 200 Lothrop St., Pittsburgh, PA, 15213
| | - Janessa M. Graves
- Washington State University College of Nursing, 103 E Spokane Falls Blvd, Spokane, WA 99202,Washington State University, Community Health Analytics Project (CHAP), Washington State University, Pullman, WA
| | - Monica S. Vavilala
- University of Washington, Harborview Injury Prevention and Research Center, 401 Broadway, 4th floor, Seattle, WA 98122,University of Washington Department of Anesthesiology and Pain Medicine, 1959 NE Pacific Street, BB-1468, Seattle, WA 98195,University of Washington Department of Pediatrics, 1959 NE Pacific Street, Box 356320, Seattle, WA 98105
| | - Adam Goldin
- Seattle Children's Hospital, Division of General and Thoracic Surgery, 4800 Sand Point Way NE, Seattle, WA 98105.
| | - Frederick P. Rivara
- University of Washington, Harborview Injury Prevention and Research Center, 401 Broadway, 4th floor, Seattle, WA 98122,University of Washington Department of Pediatrics, 1959 NE Pacific Street, Box 356320, Seattle, WA 98105
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18
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Litz CN, Amankwah EK, Polo RL, Sakmar KA, Danielson PD, Chandler NM. Outpatient management of intussusception: a systematic review and meta-analysis. J Pediatr Surg 2019; 54:1316-1323. [PMID: 30503194 DOI: 10.1016/j.jpedsurg.2018.09.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2018] [Revised: 09/10/2018] [Accepted: 09/24/2018] [Indexed: 11/25/2022]
Abstract
BACKGROUND Variability in management of intussusception after enema reduction exists. Historically, inpatient observation was recommended; however, there is a lack of evidence-based guidelines for this practice. METHODS A systematic review and meta-analysis evaluating outcomes between inpatient (IP) and outpatient (OP) management after enema reduction was performed. The following databases were searched: PubMed, EBSCOhost CINAHL, EMBASE, Web of Science, and Cochrane Database. Data from an institutional review were included in the meta-analysis. RESULTS Ten studies of patients aged 0-18 years with intussusception who underwent successful enema reduction that reported outcomes of outpatient management were included. Overall recurrence rates were 6% for IP and 8% for OP (p = 0.20). Recurrences within 24 (IP: 1% vs OP: 0%, p = 0.90) and 48 h (IP: 1% vs OP: 2%, p = 0.11) were similar. There was no significant difference in the rate of return to the emergency department (IP: 6% vs OP: 14%, p = 0.11). Both groups had a similar rate of requiring an operation (IP: 2% vs OP: 1%, p = 0.84). CONCLUSIONS Outpatient management of intussusception after enema reduction results in a shorter hospital stay with no difference in the rate of return to the emergency department, recurrence, need for operation, or mortality. The findings of the meta-analysis suggest that outpatient management may be safe and could reduce hospital resource utilization. TYPE OF STUDY Treatment study. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Cristen N Litz
- Division of Pediatric Surgery, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA.
| | - Ernest K Amankwah
- Clinical and Translational Research Organization, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - Randall L Polo
- Shimberg Health Sciences Library, University of South Florida, Tampa, FL, USA
| | - Kristen A Sakmar
- Shimberg Health Sciences Library, University of South Florida, Tampa, FL, USA
| | - Paul D Danielson
- Division of Pediatric Surgery, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - Nicole M Chandler
- Division of Pediatric Surgery, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
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Steadman RA, Harling MJ, Thomason MJ, Morgan KM, Hale AL, Ewing JA, Gates RL. Initial Fluid Resuscitation Increases Risk of Failed Pneumatic Reduction of Intussusception. Am Surg 2018. [DOI: 10.1177/000313481808401122] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
| | | | | | - Katrina M. Morgan
- School of Medicine Greenville University of South Carolina Greenville, South Carolina
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20
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Markham JL, Hall M, Bettenhausen JL, Myers AL, Puls HT, McCulloh RJ. Variation in Care and Clinical Outcomes in Children Hospitalized With Orbital Cellulitis. Hosp Pediatr 2017; 8:28-35. [PMID: 29208694 DOI: 10.1542/hpeds.2017-0040] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To describe variation in the care of children hospitalized with orbital cellulitis and to determine associations with length of stay (LOS), emergency department (ED) revisits, and hospital readmissions. METHODS By using the Pediatric Health Information System, we performed a multicenter, retrospective study of children aged 2 months to 18 years with a primary International Classification of Diseases, Ninth Revision, Clinical Modification discharge diagnosis code for orbital cellulitis from 2007 to 2014. We assessed hospital-level variation in the use of diagnostic tests, corticosteroids, and antibiotics individually and in aggregate for association with outcomes (LOS, ED revisits, readmissions) after risk-adjusting for important clinical and demographic factors. RESULTS A total of 1828 children met inclusion criteria. Complete blood cell counts (median [interquartile range]: 81.8% [66.7-89.6]), C-reactive protein levels (57.1% [22.2-84.0]), blood cultures (57.9% [48.9-63.6]), and computed tomography imaging (74.7% [66.7-81.0]) were the most frequently performed diagnostic tests, with significant variation observed across hospitals (all P < .001). Corticosteroids were used in 29.2% of children (interquartile range: 18.4-37.5). There was significant variation in antibiotic exposure across hospitals (P < .001). Increased total diagnostic test usage was associated with increased LOS (P = .044), but not with 30-day ED revisits (P = .176) or readmissions (P = .403). CONCLUSIONS Children hospitalized with orbital cellulitis experience wide variation in clinical management. Increased hospital-level usage is associated with increased LOS. Our findings highlight a critical need to identify treatment strategies that optimize resource use and outcomes for children hospitalized with orbital cellulitis.
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Affiliation(s)
| | - Matthew Hall
- Divisions of Pediatric Hospital Medicine and.,Children's Hospital Association, Lenexa, Kansas
| | | | - Angela L Myers
- Divisions of Pediatric Hospital Medicine and.,Infectious Diseases, Children's Mercy Kansas City, Kansas City, Missouri; and
| | | | - Russell J McCulloh
- Divisions of Pediatric Hospital Medicine and.,Infectious Diseases, Children's Mercy Kansas City, Kansas City, Missouri; and
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Savoie KB, Thomas F, Nouer SS, Langham MR, Huang EY. Age at presentation and management of pediatric intussusception: A Pediatric Health Information System database study. Surgery 2016; 161:995-1003. [PMID: 27842915 DOI: 10.1016/j.surg.2016.09.030] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Revised: 08/23/2016] [Accepted: 09/16/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Intussusception is uncommon in children older than 3 years, and use of enema reduction in older children is controversial. We sought to determine whether older children are at greater risk of requiring operative intervention and/or having pathology causing lead points, such that enema reduction should not be attempted. METHODS The Pediatric Health Information System database was reviewed from January 1, 2009-June 30, 2014. Patients were followed for 6 months from initial presentation or until bowel resection occurred. Successful enema reduction was defined as having radiologic reduction without additional procedures. RESULTS A total of 7,412 patients were identified: 6,681 were <3 years old, 731 patients were >3 years old. In those >3 years old, 450 (62%) were treated successfully with enema reduction; the rate of patients with a tumor diagnosis was similar in patients <3 years old and patients >3 years old (5% vs 6%, P = .07). The rate of a Meckel's diagnosis was greater in patients >3 years old (2% vs 14%, P < .0001). In patients >3 years old, duration of stay between patients who underwent primary operative therapy versus those who underwent operative therapy after enema reduction was similar (4 days vs 4 days, P = .06). Older age was not associated with increased risk of recurrent admission for intussusception (P = .45). CONCLUSION Pediatric Health Information System data suggest that enema reduction may be safe and effective for a majority of children even if older than 3 years.
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Affiliation(s)
- Kate B Savoie
- Department of General Surgery, University of Tennessee Health Science Center, Memphis, TN; College of Graduate Health Sciences, University of Tennessee Health Science Center, Memphis, TN
| | - Fridtjof Thomas
- Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN
| | - Simonne S Nouer
- Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN
| | - Max R Langham
- Department of General Surgery, University of Tennessee Health Science Center, Memphis, TN
| | - Eunice Y Huang
- Department of General Surgery, University of Tennessee Health Science Center, Memphis, TN.
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Minneman JA, Grijalva JL, LaQuaglia MJ, Kim HB, Rangel SJ, Vakili K. Variation in resource utilization in liver transplantation at freestanding children's hospitals. Pediatr Transplant 2016; 20:921-925. [PMID: 27762480 DOI: 10.1111/petr.12783] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/21/2016] [Indexed: 11/30/2022]
Abstract
We sought to examine the relationship between liver transplant-related total cost, patient outcome, and hospital resource utilization at freestanding children's hospitals. Using the PHIS database, a retrospective study of 374 patients that underwent liver transplantation at 15 freestanding children's hospitals from July 2010 to December 2012 was performed. One-year graft failure and patient mortality rates from July 2010 to December 2012 for each center were also obtained from the SRTR. There was a 5.1-fold difference in median cost (median $146 444, range $59 487-302 058, P<.001) between all centers. A 2.4-fold difference existed in median LOS (median 15 days, range 9-22 days, P<.001) across centers. Median postoperative ICU stay varied from 0 to 7 days (median 4 days, P<.001). Overall, 30-day readmission rate was 55% (31.3%-100%, P<.001). One-year graft failure varied from 0% to 19.1%, with an overall rate of 5.5% (P=.279). One-year patient mortality for all centers was 2.3% (range 0%-11.1%, P=.016). Higher total cost did not correlate with lower readmission rates, patient mortality, graft failure, or any other variable. These data suggest that identifying practice patterns at low-cost centers and implementing them at higher-cost centers may decrease the cost of pediatric liver transplantation without compromising outcomes.
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Affiliation(s)
| | - James L Grijalva
- Department of Surgery, Boston Children's Hospital, Boston, MA, USA
| | | | - Heung Bae Kim
- Department of Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Shawn J Rangel
- Department of Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Khashayar Vakili
- Department of Surgery, Boston Children's Hospital, Boston, MA, USA.
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Puckett Y, Greenspon J, Fitzpatrick C, Vane D, Bansal S, Rice M, Chatoorgoon K. Utility of hospital admission for pediatric intussusceptions. Pediatr Surg Int 2016; 32:805-9. [PMID: 27350542 DOI: 10.1007/s00383-016-3924-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/22/2016] [Indexed: 11/28/2022]
Abstract
PURPOSE The standard practice in pediatric patients diagnosed with intussusception has been reduction via enema and admission for a period of nil per os and observation. Little data exists to support this practice. The objective of this study was to examine whether post-reduction admission to hospital is required. METHODS A retrospective chart review was performed on all patients aged 0-18 years old with intussusception over a span of 20 years. Study included children treated for intussusception on first encounter with enema and subsequently admitted for observation. Study excluded those readmitted for recurrence after 48 h, patients whose intussusception did not reduce on first try, those lost to follow-up, and those who went to the operating room. Early recurrence was defined as recurrence within 48 h post-reduction. RESULTS Out of 171 patients admitted, only one experienced an early recurrence (0.6 %). Median length of stay for all patients was 2 days. Average cost incurred per day for intussusception admission was $404. CONCLUSION Intussusception in a child that is successfully reduced via enema has a low recurrence rate and is usually followed by prompt resolution of symptoms. An abbreviated period of observation in the emergency department post-reduction may result in healthcare savings.
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Affiliation(s)
- Yana Puckett
- Department of Pediatric Surgery, SSM Health Cardinal Glennon Children's Hospital, Saint Louis University School of Medicine, 1465 South Grand Blvd, Saint Louis, MO, 63104, USA.
| | - Jose Greenspon
- Department of Pediatric Surgery, SSM Health Cardinal Glennon Children's Hospital, Saint Louis University School of Medicine, 1465 South Grand Blvd, Saint Louis, MO, 63104, USA
| | - Colleen Fitzpatrick
- Department of Pediatric Surgery, SSM Health Cardinal Glennon Children's Hospital, Saint Louis University School of Medicine, 1465 South Grand Blvd, Saint Louis, MO, 63104, USA
| | - Dennis Vane
- Department of Pediatric Surgery, SSM Health Cardinal Glennon Children's Hospital, Saint Louis University School of Medicine, 1465 South Grand Blvd, Saint Louis, MO, 63104, USA
| | - Samiksha Bansal
- Department of Pediatric Surgery, SSM Health Cardinal Glennon Children's Hospital, Saint Louis University School of Medicine, 1465 South Grand Blvd, Saint Louis, MO, 63104, USA
| | - Mandy Rice
- Department of Pediatric Surgery, SSM Health Cardinal Glennon Children's Hospital, Saint Louis University School of Medicine, 1465 South Grand Blvd, Saint Louis, MO, 63104, USA
| | - Kaveer Chatoorgoon
- Department of Pediatric Surgery, SSM Health Cardinal Glennon Children's Hospital, Saint Louis University School of Medicine, 1465 South Grand Blvd, Saint Louis, MO, 63104, USA
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Meta-analysis of Air Versus Liquid Enema for Intussusception Reduction in Children. AJR Am J Roentgenol 2016; 205:W542-9. [PMID: 26496576 DOI: 10.2214/ajr.14.14060] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The purpose of this study was to assess the effectiveness and safety of air versus liquid enema reduction in the treatment of intussusception in children. MATERIALS AND METHODS Literature searches of the PubMed, Embase, and Cochrane Library databases were conducted from January 1, 1966, through May 31, 2013. Articles on the use of air or liquid enema in children with a confirmed diagnosis of intussusception and reporting either a success rate for enema reduction of intussusception or a perforation rate were selected. Enema reduction success rate, perforation rate, and recurrence rate were the main outcomes and were calculated by random effects modeling. RESULTS One hundred two articles (101 reporting success rate, 71 reporting perforation rate) were included that presented results for 32,451 children (age range, 1 day-22 years; boys, 66%; girls, 34%). In 44 studies (16,187 children), the combined estimate for success rate of air enema was 82.7% (95% CI, 79.9-85.6%; inconsistency index [I(2)] = 97%), and in 52 studies (13,081 children) of liquid enema, it was 69.6% (95% CI, 65.0-74.1%; I(2) = 98%). In 38 studies (15,752 children), the combined estimate of perforation rate for air enema was 0.39% (95% CI, 0.23- 0.55%; I(2) = 40%), and in 30 studies (9429 children) of liquid enema, it was 0.43% (95% CI, 0.24- 0.62%; I(2) = 9%). Among 10,494 children (26 studies) undergoing air enema reduction, the rate of first intussusception recurrence was 6% (95% CI, 4.5-7.5%; I(2) = 89%), similar to the 7.3% (95% CI, 5.8-8.8%; I(2) = 71%) found for 4004 children (24 studies) undergoing liquid enema reduction. CONCLUSION Air enema was superior to liquid enema for intussusception reduction. The success rate was higher without a difference in perforation rate. Limitations included heterogeneity and publication bias.
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Raol N, Zogg CK, Boss EF, Weissman JS. Inpatient Pediatric Tonsillectomy: Does Hospital Type Affect Cost and Outcomes of Care? Otolaryngol Head Neck Surg 2015; 154:486-93. [PMID: 26701174 DOI: 10.1177/0194599815621739] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Accepted: 11/19/2015] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To ascertain whether hospital type is associated with differences in total cost and outcomes for inpatient tonsillectomy. STUDY DESIGN Cross-sectional analysis of the 2006, 2009, and 2012 Kids' Inpatient Database (KID). SUBJECTS AND METHODS Children ≤18 years of age undergoing tonsillectomy with/without adenoidectomy were included. Risk-adjusted generalized linear models assessed for differences in hospital cost and length of stay (LOS) among children managed by (1) non-children's teaching hospitals (NCTHs), (2) children's teaching hospitals (CTHs), and (3) nonteaching hospitals (NTHs). Risk-adjusted logistic regression compared the odds of major perioperative complications (hemorrhage, respiratory failure, death). Models accounted for clustering of patients within hospitals, were weighted to provide national estimates, and controlled for comorbidities. RESULTS The 25,685 tonsillectomies recorded in the KID yielded a national estimate of 40,591 inpatient tonsillectomies performed in 2006, 2009, and 2012. The CTHs had significantly higher risk-adjusted total cost and LOS per tonsillectomy compared with NCTHs and NTHs ($9423.34/2.8 days, $6250.78/2.11 days, and $5905.10/2.08 days, respectively; P < .001). The CTHs had higher odds of complications compared with NCTHs (odds ratio [OR], 1.48; 95% CI, 1.15-1.91; P = .002) but not when compared with NTHs (OR, 1.19; 95% CI, 0.89-1.59; P = .23). The CTHs were significantly more likely to care for patients with comorbidities (P < .001). CONCLUSION Significant differences in costs, outcomes, and patient factors exist for inpatient tonsillectomy based on hospital type. Although reasons for these differences are not discernable using isolated claims data, findings provide a foundation to further evaluate patient, institutional, and system-level factors that may reduce cost of care and improve value for inpatient tonsillectomy.
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Affiliation(s)
- Nikhila Raol
- Center for Surgery and Public Health, Harvard Medical School and Harvard T. H. Chan School of Public Health, Department of Surgery, Brigham & Women's Hospital, Boston, Massachusetts, USA Massachusetts Eye and Ear Infirmary, Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA
| | - Cheryl K Zogg
- Center for Surgery and Public Health, Harvard Medical School and Harvard T. H. Chan School of Public Health, Department of Surgery, Brigham & Women's Hospital, Boston, Massachusetts, USA
| | - Emily F Boss
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | - Joel S Weissman
- Center for Surgery and Public Health, Harvard Medical School and Harvard T. H. Chan School of Public Health, Department of Surgery, Brigham & Women's Hospital, Boston, Massachusetts, USA
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Raval MV, Minneci PC, Deans KJ, Kurtovic KJ, Dietrich A, Bates DG, Rangel SJ, Moss RL, Kenney BD. Improving Quality and Efficiency for Intussusception Management After Successful Enema Reduction. Pediatrics 2015; 136:e1345-52. [PMID: 26459654 DOI: 10.1542/peds.2014-3122] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/19/2015] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES The purpose of this project was to implement a protocol facilitating discharge from the emergency department (ED) after successful radiologic ileocolic intussusception reduction in a pediatric referral center. METHODS A multidisciplinary team identified drivers for successful quality improvement including educational brochures, a standardized radiologic report, an observation period in the ER with oral hydration challenges, and follow-up phone calls the day after discharge. Patient outcomes were tracked, and quarterly feedback was provided. RESULTS Of 80 patients identified over a 24-month period, 34 (42.5%) did not qualify for discharge home due to need for surgical intervention (n = 9), specific radiologic findings (n = 11), need for additional intravenous hydration (n = 4), or other reasons (n = 7). Of 46 patients who qualified for discharge, 30 (65.2%) were successfully sent home from the ED. One patient returned with recurrent symptoms that required repeat enema reduction. Sixteen patients were observed and discharged within 23 hours. Adherence with discharge from the ED improved over time. Discharge from the ED was associated with cost savings and improved net margins at the hospital level for each encounter. CONCLUSIONS A sustainable multidisciplinary quality improvement project to discharge intussusception patients from the ED after air-contrast enema reduction was successfully integrated in a high-volume referral center through education, standardized radiologic reporting, and protocoled follow-up.
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Affiliation(s)
- Mehul V Raval
- Division of Pediatric Surgery, Department of Surgery, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia;
| | | | | | - Kelli J Kurtovic
- Quality Improvement Services, Nationwide Children's Hospital, Columbus, Ohio
| | - Ann Dietrich
- Ohio University College of Medicine, Athens, Ohio; and
| | - D Gregory Bates
- Department of Radiology, Nationwide Children's Hospital, The Ohio State University School of Medicine, Columbus, Ohio
| | - Shawn J Rangel
- Division of Pediatric Surgery, Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Brian D Kenney
- Division of Pediatric Surgery, Department of Surgery, and
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Lessenich EM, Kimia AA, Mandeville K, Li J, Landschaft A, Tsai A, Bachur RG. The Frequency of Postreduction Interventions After Successful Enema Reduction of Intussusception. Acad Emerg Med 2015; 22:1042-7. [PMID: 26292193 DOI: 10.1111/acem.12741] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Revised: 03/13/2015] [Accepted: 04/17/2015] [Indexed: 11/28/2022]
Abstract
OBJECTIVES The objective was to determine the frequency of postreduction, hospital-level interventions among children with successful reduction of ileocolic intussusception and identify factors that predict the need for such interventions. METHODS This was a retrospective cross-sectional study of children who underwent successful enema reduction for ileocolic intussusception at a single emergency department. Hospital-level interventions were included if they occurred within 24 hours of reduction and were further classified as either major (recurrence or possible perforation) or minor (imaging for suspected recurrence or administration of parenteral narcotics or antiemetics). Binary logistic regression was used to identify predictors for hospital-level interventions. RESULTS A total of 464 children underwent enema reduction. The median age was 1.7 years (interquartile range [IQR] = 0.8 to 2.5 years), and 66% were male. A total of 435 (94%) were hospitalized with a median hospital stay of 25 hours (IQR = 19 to 34 hours). Nineteen percent (95% confidence interval [CI] = 15% to 22%) needed postreduction interventions, including 6% (95% CI = 4% to 9%) who required major interventions. The median time to any hospital intervention was 9.9 hours (IQR = 6.3 to 16.4 hours). We identified two independent predictors for hospital-level interventions: duration of symptoms > 24 hours (adjusted odds ratio [OR] = 2.1, 95% CI = 1.3 to 3.4) and location of the intussusception tip at (or proximal to) the hepatic flexure (adjusted OR = 1.9, 95% CI = 1.1 to 3.3); the latter factor was also a predictor of a major intervention. None of the children (95% CI = 0 to 1.0%) had an acute decompensation after an initially successful enema reduction. CONCLUSIONS Clinical decompensation is rare and recurrence is relatively low after an uncomplicated reduction of ileocolic intussusception. However, one in five children required hospital-level interventions after reduction. Children with the intussusception tip at (or proximal to) the hepatic flexure, and those with symptoms for longer than 24 hours, are more likely to require subsequent interventions. Although outpatient management appears safe after a period of observation, caregivers should be counseled about the risk of ongoing symptoms and recurrence.
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Affiliation(s)
| | - Amir A. Kimia
- Division of Emergency Medicine; Department of Medicine; Children's Hospital Boston; Boston MA
| | - Katherine Mandeville
- Division of Emergency Medicine; Department of Medicine; Children's Hospital Boston; Boston MA
| | - Joyce Li
- Division of Emergency Medicine; Department of Medicine; Children's Hospital Boston; Boston MA
| | - Assaf Landschaft
- Division of Emergency Medicine; Department of Medicine; Children's Hospital Boston; Boston MA
| | - Andy Tsai
- Department of Radiology; Children's Hospital Boston; Boston MA
| | - Richard G. Bachur
- Division of Emergency Medicine; Department of Medicine; Children's Hospital Boston; Boston MA
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Fotso Kamdem A, Nerich V, Auber F, Jantchou P, Ecarnot F, Woronoff-Lemsi MC. Quality assessment of economic evaluation studies in pediatric surgery: a systematic review. J Pediatr Surg 2015; 50:659-87. [PMID: 25840083 DOI: 10.1016/j.jpedsurg.2015.01.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2014] [Revised: 12/27/2014] [Accepted: 01/14/2015] [Indexed: 01/20/2023]
Abstract
PURPOSE To assess economic evaluation studies (EES) in pediatric surgery and to identify potential factors associated with high-quality studies. METHODS A systematic review of the literature using PubMed and Cochrane databases was conducted to identify EES in pediatric surgery published between 1 June 1993 and 30 June 2013. Assessment criteria are derived from the Drummond checklist. A high quality study was defined as a Drummond score ≥7. Logistic regression analysis was used to determine factors associated with high quality studies. RESULTS 119 studies were included. 43.7% (n=52) of studies were full EES. Cost-effectiveness analysis was the most frequent (61.5%) type of full EES. Only 31.6% of studies had a Drummond score ≥7 and 73% of these were full EES. The factors associated with high quality were identification of costs (OR: 14.08; 95% CI: 3.38-100; p<0.001), estimation of utility value (OR: 8.13; 95% CI: 2.02-43.47; p=0.005) and study funding (OR: 3.50; 95% CI: 1.27-10.10; p=0.02). CONCLUSION This review shows that the number and the quality of EES are low despite the increasing number of studies published in recent years. In the current context of budget constraints, our results should encourage pediatric surgeons to focus more on EES.
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Affiliation(s)
- Arnaud Fotso Kamdem
- UMR-INSERM-1098, Department of Pediatric Surgery, Besançon University Hospital, 3 Boulevard Fleming, F-25000 Besancon, France.
| | - Virginie Nerich
- INSERM U645 EA-2284 IFR-133, Department of Pharmacy, Besançon University Hospital, 3 Boulevard Fleming, F-25000 Besancon, France.
| | - Frederic Auber
- UMR-INSERM-1098, Department of Pediatric Surgery, Besançon University Hospital, 3 Boulevard Fleming, F-25000 Besancon, France.
| | - Prévost Jantchou
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Sainte-Justine University Hospital, 3175, Chemin de la Côte Sainte-Catherine, H3T 1C5, Montréal, Quebec, Canada.
| | - Fiona Ecarnot
- EA3920, Department of Cardiology, Besançon University Hospital, 3 Boulevard Fleming, F-25000 Besançon, France.
| | - Marie-Christine Woronoff-Lemsi
- UMR-INSERM-1098, Department of Clinical Research and Innovation, Besançon University Hospital, 2 place Saint Jacques, F-25000 Besançon, France.
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Lautz TB, Thurm CW, Rothstein DH. Delayed repeat enemas are safe and cost-effective in the management of pediatric intussusception. J Pediatr Surg 2015; 50:423-7. [PMID: 25746701 DOI: 10.1016/j.jpedsurg.2014.09.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2014] [Revised: 09/01/2014] [Accepted: 09/02/2014] [Indexed: 12/21/2022]
Abstract
BACKGROUND/PURPOSE The purpose of the study is to compare outcomes between delayed repeat enema (DRE) and immediate surgery (IS) in children with ileocolic intussusception who fail initial enema reduction. METHODS Retrospective cohort study of children <6 years-of-age from 2008 to 2012 in the Pediatric Health Information System (PHIS) database. Outcomes measured were bowel resection, length of stay (LOS), and adjusted hospital costs (AHC). RESULTS 4980 of 6889 (72.3%) children with intussusception were discharged without operation following a single successful enema. 1407 of 1909 (73.7%) remaining patients underwent IS while 502 (26.3%) had a DRE. Bowel resection was required in 372 of 1407 (26.4%) patients in IS group compared to 59 of 502 (11.8%) in the DRE group (p<0.001). The number of patients needed to treat by DRE to prevent a bowel resection was 7. In multivariable analysis, the IS patients had a 2.5 times greater likelihood of undergoing bowel resection than the DRE patients (adjusted odds ratio [OR] 2.50, 95% confidence interval [CI] 1.83-3.41, p<0.001). The DRE group had a mean LOS of 3.2 days (95% CI 2.9-3.6) and mean AHC of $9205 (95% CI $7673-$10,735). The IS group had a longer LOS (4.4days, 95% CI 4.0-4.8, p≤0.001) and higher AHC ($14,422, 95% CI $12,631-$16,214, p<0.001). CONCLUSION Delayed repeat enemas for ileocolic intussusception increase the success of nonoperative reduction, decrease the rate of bowel resection and reduce mean hospital length of stay and costs.
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Affiliation(s)
- Timothy B Lautz
- Division of Pediatric Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago and Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
| | - Cary W Thurm
- Children's Hospital Association, Overland Park, KS, USA
| | - David H Rothstein
- Division of Pediatric Surgery, Women and Children's Hospital of Buffalo, Buffalo, NY 14222, USA
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Sulkowski JP, Cooper JN, McConnell PI, Pasquali SK, Shah SS, Minneci PC, Deans KJ. Variability in noncardiac surgical procedures in children with congenital heart disease. J Pediatr Surg 2014; 49:1564-9. [PMID: 25475794 PMCID: PMC4259048 DOI: 10.1016/j.jpedsurg.2014.06.001] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2013] [Revised: 05/30/2014] [Accepted: 06/02/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND The purpose of this study was to examine the volume and variability of noncardiac surgeries performed in children with congenital heart disease (CHD) requiring cardiac surgery in the first year of life. METHODS Patients who underwent cardiac surgery by 1 year of age and had a minimum 5-year follow-up at 22 of the hospitals contributing to the Pediatric Health Information System database between 2004 and 2012 were included. Frequencies of noncardiac surgical procedures by age 5 years were determined and categorized by subspecialty. Patients were stratified according to their maximum RACHS-1 (Risk Adjustment in Congenital Heart Surgery) category. The proportions of patients across hospitals who had a noncardiac surgical procedure for each subspecialty were compared using logistic mixed effects models. RESULTS 8857 patients underwent congenital heart surgery during the first year of life, 3621 (41%) of whom had 13,894 noncardiac surgical procedures by 5 years. Over half of all procedures were in general surgery (4432; 31.9%) or otolaryngology (4002; 28.8%). There was significant variation among hospitals in the proportion of CHD patients having noncardiac surgical procedures. Compared to children in the low risk group (RACHS-1 categories 1-3), children in the high-risk group (categories 4-6) were more likely to have general, dental, orthopedic, and thoracic procedures. CONCLUSIONS Children with CHD requiring cardiac surgery frequently also undergo noncardiac surgical procedures; however, considerable variability in the frequency of these procedures exists across hospitals. This suggests a lack of uniformity in indications used for surgical intervention. Further research should aim to better standardize care for this complex patient population.
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Affiliation(s)
- Jason P. Sulkowski
- Center for Surgical Outcomes Research and Center for Innovation in Pediatric Practice, The Research Institute at Nationwide Children’s Hospital, Columbus, OH,Department of Surgery, Nationwide Children’s Hospital, Columbus, OH
| | - Jennifer N. Cooper
- Center for Surgical Outcomes Research and Center for Innovation in Pediatric Practice, The Research Institute at Nationwide Children’s Hospital, Columbus, OH
| | - Patrick I. McConnell
- Division of Cardiothoracic Surgery, Nationwide Children’s Hospital, Columbus, OH
| | - Sara K. Pasquali
- Division of Cardiology, Department of Pediatrics, University of Michigan C.S. Mott Children’s Hospital, Ann Arbor, MI
| | - Samir S. Shah
- Division of Hospital Medicine, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Peter C. Minneci
- Center for Surgical Outcomes Research and Center for Innovation in Pediatric Practice, The Research Institute at Nationwide Children’s Hospital, Columbus, OH,Department of Surgery, Nationwide Children’s Hospital, Columbus, OH
| | - Katherine J. Deans
- Center for Surgical Outcomes Research and Center for Innovation in Pediatric Practice, The Research Institute at Nationwide Children’s Hospital, Columbus, OH,Department of Surgery, Nationwide Children’s Hospital, Columbus, OH
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Beres AL, Baird R, Fung E, Hsieh H, Abou-Khalil M, Ted Gerstle J. Comparative outcome analysis of the management of pediatric intussusception with or without surgical admission. J Pediatr Surg 2014; 49:750-2. [PMID: 24851762 DOI: 10.1016/j.jpedsurg.2014.02.059] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2014] [Accepted: 02/13/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Controversy persists about the need to admit patients after successful reduction of intussusception. Our hypothesis is that pediatric intussusception can be managed with discharge from the emergency department (ED) after reduction without increasing morbidity, yielding significant cost savings. METHODS A chart review over 10 years was performed at two Canadian institutions. Data abstracted included: demographics, length of stay (LOS), initial and recurrence management. Primary outcome was early recurrence and resultant management, including LOS and need for operative intervention. Costs were calculated using hospital-specific data. RESULTS 584 patient records were assessed: 329 patients were managed with admission after reduction, 239 as outpatients. In the admission group, 28 patients had at least one recurrence (8.5%), with 8 after discharge. In the outpatient group, 21 patients had at least one recurrence (8.8%), with 19 after discharge. The difference post-discharge was significant (p=0.004). Outcomes of recurrence did not differ, with 2 patients in each group requiring operative intervention. Average LOS in the admission group was 90 h, with additional average cost of $1771 per non-operated patient. CONCLUSIONS Pediatric intussusception can be safely managed as an outpatient with reliable follow up. Discharge from the ED reduces hospital charges without increasing morbidity. This approach should be considered in managing patients with intussusception.
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Affiliation(s)
- Alana L Beres
- The Montreal Children's Hospital, Pediatric General and Thoracic Surgery, McGill University Health Centre
| | - Robert Baird
- The Montreal Children's Hospital, Pediatric General and Thoracic Surgery, McGill University Health Centre.
| | - Eleanor Fung
- The Hospital for Sick Children, Division of General and Thoracic Surgery, University of Toronto
| | - Helen Hsieh
- The Montreal Children's Hospital, Pediatric General and Thoracic Surgery, McGill University Health Centre
| | - Maria Abou-Khalil
- The Montreal Children's Hospital, Pediatric General and Thoracic Surgery, McGill University Health Centre
| | - J Ted Gerstle
- The Hospital for Sick Children, Division of General and Thoracic Surgery, University of Toronto
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Greene NH, Kernic MA, Vavilala MS, Rivara FP. Variation in pediatric traumatic brain injury outcomes in the United States. Arch Phys Med Rehabil 2014; 95:1148-55. [PMID: 24631594 DOI: 10.1016/j.apmr.2014.02.020] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2013] [Revised: 02/07/2014] [Accepted: 02/20/2014] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To ascertain the degree of variation, by state of hospitalization, in outcomes associated with traumatic brain injury (TBI) in a pediatric population. DESIGN A retrospective cohort study of pediatric patients admitted to a hospital with a TBI. SETTING Hospitals from states in the United States that voluntarily participate in the Agency for Healthcare Research and Quality's Healthcare Cost and Utilization Project. PARTICIPANTS Pediatric (age ≤ 19 y) patients hospitalized for TBI (N=71,476) in the United States during 2001, 2004, 2007, and 2010. INTERVENTIONS None. MAIN OUTCOME MEASURES Primary outcome was proportion of patients discharged to rehabilitation after an acute care hospitalization among alive discharges. The secondary outcome was inpatient mortality. RESULTS The relative risk of discharge to inpatient rehabilitation varied by as much as 3-fold among the states, and the relative risk of inpatient mortality varied by as much as nearly 2-fold. In the United States, approximately 1981 patients could be discharged to inpatient rehabilitation care if the observed variation in outcomes was eliminated. CONCLUSIONS There was significant variation between states in both rehabilitation discharge and inpatient mortality after adjusting for variables known to affect each outcome. Future efforts should be focused on identifying the cause of this state-to-state variation, its relationship to patient outcome, and standardizing treatment across the United States.
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Affiliation(s)
- Nathaniel H Greene
- Department of Anesthesiology and Pain Medicine, School of Medicine, University of Washington, Seattle, WA; Harborview Injury Prevention and Research Center, University of Washington, Seattle, WA.
| | - Mary A Kernic
- Harborview Injury Prevention and Research Center, University of Washington, Seattle, WA; Department of Epidemiology, School of Public Health, University of Washington, Seattle, WA
| | - Monica S Vavilala
- Department of Anesthesiology and Pain Medicine, School of Medicine, University of Washington, Seattle, WA; Harborview Injury Prevention and Research Center, University of Washington, Seattle, WA; Department of Pediatrics, School of Medicine, University of Washington, Seattle, WA
| | - Frederick P Rivara
- Harborview Injury Prevention and Research Center, University of Washington, Seattle, WA; Department of Epidemiology, School of Public Health, University of Washington, Seattle, WA; Department of Pediatrics, School of Medicine, University of Washington, Seattle, WA
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Papic JC, Finnell SME, Leys CM, Bennett WE, Downs SM. Referring physicians' decision making for pediatric anti-reflux procedures. Surgery 2013; 155:851-9. [PMID: 24787112 DOI: 10.1016/j.surg.2013.12.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Accepted: 12/10/2013] [Indexed: 11/30/2022]
Abstract
BACKGROUND Rates of anti-reflux procedures (ARP) vary greatly among pediatric hospitals. How pediatric subspecialists make referral decisions for ARPs has not been described. The aim of this study was to characterize pediatric subspecialists' decision making for referring children for ARPs. METHODS Pediatric subspecialists at a single children's hospital were interviewed about their decision making when referring for ARPs. Qualitative analysis was performed on clinicians' perceptions of the risks and benefits of the treatment options. Clinical algorithms were derived from each interview and were compared using the Clinical Algorithm Nosology. Clinical Algorithm Structural Analysis (CASA) scores were calculated to assess algorithm complexity. Clinical Algorithm Patient Abstraction (CAPA) scores on a scale from 0 (different) to 10 (identical) were generated based on algorithm agreement. RESULTS The interviews yielded 15 algorithms. There was substantial variation in the providers' perceived risks and benefits of the treatment options. CASA scores ranged from 8 to 28 and CAPA scores ranged from 0 to 5.7 (median, 0), indicating great variation in both complexity and patient management. Management variation included testing (33% of algorithms incorporated pH probe test, 67% upper gastrointestinal, and 47% small bowel follow-through), procedure contraindications (33% considered history of gagging a contraindication to ARP), and use of gastrojejunostomy tubes (20% using gastrojejunostomy tube before ARP). CONCLUSION No standards exist for the decision to refer children with gastroesophageal reflux disease for ARP. There is great variation among pediatric subspecialists in their decision making. Differences in providers' perception of the risks and benefits of these procedures contribute to this variation.
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Affiliation(s)
- Jonathan C Papic
- Division of Pediatric Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN.
| | - S Maria E Finnell
- Division of Pediatric Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN; Children's Health Services Research, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN
| | - Charles M Leys
- Division of Pediatric Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - William E Bennett
- Children's Health Services Research, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN; Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN
| | - Stephen M Downs
- Children's Health Services Research, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN; Regenstrief Institute, Inc, Indianapolis, IN
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An institutional analysis and systematic review with meta-analysis of pneumatic versus hydrostatic reduction for pediatric intussusception. Surgery 2013; 154:328-34. [PMID: 23889959 DOI: 10.1016/j.surg.2013.04.036] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2013] [Accepted: 04/19/2013] [Indexed: 11/21/2022]
Abstract
BACKGROUND Intussusception remains a frequent cause of bowel obstruction in children and typically is treated by reduction via enema. Controversy persists regarding the optimal reduction technique to maximize success while minimizing morbidity. METHODS We reviewed our institutional data comparing outcomes of enema reduction that use contrast medium versus air. A systematic review also was undertaken of comparative studies evaluating pneumatic (oxygen or air) versus hydrostatic (any contrast medium) reduction. Critical appraisal was performed with the Methodological Index for Non Randomized Studies scale for observational studies, Jadad score for randomized trials. Meta-analysis was performed with REVMAN 5.1. RESULTS Institutional data revealed a failed reduction rate of 20.4% (20/98) with air and 29.6% (8/27) with contrast reduction. Nineteen studies were included in the systematic review. The cumulative failure rate favored pneumatic reduction (odds ratio [OR] 0.45; 95% confidence interval [95% CI] 0.34-0.60); sensitivity analysis of prospective studies demonstrated similar results (OR 0.39; 95% CI 0.24-0.63). The number needed to treat to eliminate one failed reduction was nine pneumatic reductions. No difference was noted in reported perforations (OR 0.98; 95% CI 0.48-2.03). CONCLUSION Pneumatic reduction is more likely to successfully reduce intussusception in children without evidence of increased morbidity. In the context of available expertise, pneumatic reduction should be the method of choice for the treatment of intussusception barring an indication for immediate operative intervention.
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