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Faitna P, Harwood R, Kenny SE, Viner RM, Aylin PP, Hargreaves DS, Bottle A. Impact of the COVID-19 pandemic on the clinical management trends for acute appendicitis among the under-25s: a retrospective study. Arch Dis Child 2024; 109:339-346. [PMID: 38325911 PMCID: PMC10958286 DOI: 10.1136/archdischild-2023-326313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 01/12/2024] [Indexed: 02/09/2024]
Abstract
OBJECTIVE To describe the COVID-19 pandemic's impact on acute appendicitis management on children and young people (CYP). DESIGN Retrospective cohort study. SETTING All English National Health Service hospitals. PATIENTS Acute appendicitis admissions (all, simple, complex) by CYP (under-5s, 5-9s, 10-24s). EXPOSURE Study pandemic period: February 2020-March 2021. Comparator pre-pandemic period: February 2015-January 2020. MAIN OUTCOME MEASURES Monthly appendicectomy and laparoscopic appendicectomy rate trends and absolute differences between pandemic month and the pre-pandemic average. Proportions of appendicitis admissions comprising complex appendicitis by hospital with or without specialist paediatric centres were compared. RESULTS 101 462 acute appendicitis admissions were analysed. Appendicectomy rates fell most in April 2020 for the 5-9s (-18.4% (95% CI -26.8% to -10.0%)) and 10-24s (-28.4% (-38.9% to -18.0%)), driven by reductions in appendicectomies for simple appendicitis. This was equivalent to -54 procedures (-68.4 to -39.6) and -512 (-555.9 to -467.3) for the 5-9s and 10-24s, respectively. Laparoscopic appendicectomies fell in April 2020 for the 5-9s (-15.5% (-23.2% to -7.8%)) and 10-24s (-44.8% (-57.9% to -31.6%) across all types, which was equivalent to -43 (-56.1 to 30.3) and -643 (-692.5 to -593.1) procedures for the 5-9s and 10-24s, respectively. A larger proportion of complex appendicitis admissions were treated within trusts with specialist paediatric centres during the pandemic. CONCLUSIONS For CYP across English hospitals, a sharp recovery followed a steep reduction in appendicectomy rates in April 2020, due to concerns with COVID-19 transmission. This builds on smaller-sized studies reporting the immediate short-term impacts.
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Affiliation(s)
- Puji Faitna
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
| | - Rachel Harwood
- Department of Paediatric Surgery, Alder Hey Children's Hospital, Liverpool, UK
| | - Simon E Kenny
- Department of Paediatric Surgery, Alder Hey Children's Hospital, Liverpool, UK
- National Clinical Director for Children and Young People, NHS England and NHS Improvement, London, UK
- Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| | - Russell M Viner
- Population, Policy and Practice Research Programme, UCL Institute of Child Health, London, UK
| | - Paul P Aylin
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
| | - Dougal S Hargreaves
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
- Mohn Centre for Children's Health and Wellbeing, Imperial College London, London, UK
| | - Alex Bottle
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
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Marquart J, Salazar JH, Bergner C, Farazi M, Van Arendonk KJ. Location of Treatment Among Infants Requiring Complex Surgical Care. J Surg Res 2023; 292:214-221. [PMID: 37634425 DOI: 10.1016/j.jss.2023.07.032] [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: 03/01/2023] [Revised: 06/13/2023] [Accepted: 07/01/2023] [Indexed: 08/29/2023]
Abstract
INTRODUCTION Rural children have worse health outcomes compared to urban children. One mechanism for this finding may be decreased access to specialized care at children's hospitals. The objective of this study was to evaluate the hospital types where complex surgical care in infants is performed nationally. METHODS This study examined infants (<1 y old) in the Kids' Inpatient Database from 2009 to 2019 who underwent surgery for one of the following conditions: esophageal atresia, gastroschisis, omphalocele, Hirschsprung disease, anorectal malformation, pyloric stenosis, small bowel atresia, congenital diaphragmatic hernia, and necrotizing enterocolitis. The relationship between patient residence (rural versus urban) and location of surgical care (children's hospital versus other) was compared in relation to other covariates using multivariable logistic regression models. RESULTS Among 29,185 infants undergoing these operations, 16.0% lived in a rural area. Rural infants were more frequently White (64.8% versus 43.4% P < 0.001), from the lowest two income quartiles (86.5% versus 52.0%, P < 0.001), and from the South or Midwest regions (P < 0.001). Surgical care was predominantly (94.1%) provided at urban teaching hospitals but frequently not at children's hospitals, especially among rural infants. After adjusting for other covariates, rural infants were significantly less likely to undergo care at a children's hospital for both 2009 (adjusted odds ratio 0.66, P < 0.001) and 2012-2019 (adjusted odds ratio 0.78, P < 0.001). CONCLUSIONS A sizable portion of complex surgical care in infants is performed outside children's hospitals, especially among those from rural areas. Further work is necessary to ensure adequate access to children's hospitals for rural children.
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Affiliation(s)
- John Marquart
- Department of Surgery, Pediatric General Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin.
| | - Jose H Salazar
- Department of Surgery, Pediatric General Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Carisa Bergner
- Department of Surgery, Pediatric General Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Manzur Farazi
- Department of Surgery, Pediatric General Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Kyle J Van Arendonk
- Department of Surgery, Pediatric General Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
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McCarthy IM, Raval MV. Price spillovers and specialization in health care: The case of children's hospitals. HEALTH ECONOMICS 2023; 32:2408-2423. [PMID: 37421641 DOI: 10.1002/hec.4734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 05/22/2023] [Accepted: 06/25/2023] [Indexed: 07/10/2023]
Abstract
Specialty hospitals tend to negotiate higher commercial insurance payments, even for relatively routine procedures with comparable clinical quality across hospital types. How specialty hospitals can maintain such a price premium remains an open question. In this paper, we examine a potential (horizontal) differentiation effect in which patients perceive specialty hospitals as sufficiently distinct from other hospitals, so that specialty hospitals effectively compete in a separate market from general acute care hospitals. We estimate this effect in the context of routine pediatric procedures offered by both specialty children's hospitals as well as general acute care hospitals, and we find strong empirical evidence of a differentiation effect in which specialty children's hospitals appear largely immune to competitive forces from non-children's hospitals.
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Gadepalli SK, Leraas HJ, Flynn-O'Brien KT, Van Arendonk KJ, Hall M, Tracy ET, Ricca RL, Goldin AB, Ehrlich PF. Changing Landscape of Routine Pediatric Surgery for Rural and Urban Children: A Report From the Child Health Evaluation of Surgical Services (CHESS) Group. Ann Surg 2023; 278:530-537. [PMID: 37497661 DOI: 10.1097/sla.0000000000005990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
Abstract
OBJECTIVE To describe the changes to routine pediatric surgical care over the past 2 decades for children living in urban and rural environments. BACKGROUND A knowledge gaps exists regarding trends in the location where routine pediatric surgical care is provided to children from urban and rural environments over time. METHODS Children (age 0-18) undergoing 7 common surgeries were identified using State Inpatient Databases (SID, 2002-2017). Rural-Urban Commuting Area codes were used to classify patient and hospital zip codes. Multivariable regression models for distance traveled >60 miles and transfer status were used to compare rural and urban populations, adjusting for year, age, sex, race, and insurance status. RESULTS Among 143,467 children, 13% lived in rural zip codes. The distance traveled for care increased for both rural and urban children for all procedures but significantly more for the rural cohort (eg, 102% vs 30%, P <0.001, cholecystectomy). Transfers also increased for rural children (eg, transfers for appendectomy increased from 1% in 2002 to 23% in 2017, P <0.001). Factors associated with the need to travel >60 miles included year [adjusted odds ratio (aOR)=2.18, 95% CI: 1.94-2.46: 2017 vs 2002], rural residence (aOR=6.55, 95% CI: 6.11-7.01), age less than 5 years (aOR=2.17, 95% CI: 1.92-2.46), and Medicaid insurance (aOR=1.35, 95% CI: 1.26-1.45). Factors associated with transfer included year (aOR=5.77, 95% CI: 5.26-6.33: 2017 vs 2002), rural residence (aOR=1.47, 95% CI: 1.39-1.56), age less than 10 years (aOR=2.34, 95% CI: 2.15-2.54), and Medicaid insurance (aOR=1.49, 95% CI: 1.42-1.46). CONCLUSION Rural children, younger age, and those on Medicaid disproportionately traveled greater distances and were more frequently transferred for common pediatric surgical procedures.
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Affiliation(s)
- Samir K Gadepalli
- Section of Pediatric Surgery, Department of Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI
| | - Harold J Leraas
- Division of Pediatric Surgery, Duke University Medical Center, Durham, NC
| | | | - Kyle J Van Arendonk
- Department of Surgery, Division of Pediatric Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Matt Hall
- Children's Hospital Association, Lenexa, KS
| | - Elisabeth T Tracy
- Division of Pediatric Surgery, Duke University Medical Center, Durham, NC
| | - Robert L Ricca
- Division of Pediatric Surgery, University of South Carolina, Prisma Health Upstate, Greenville Memorial Hospital, Greenville, SC
| | - Adam B Goldin
- Division of Pediatric General and Thoracic Surgery, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA
| | - Peter F Ehrlich
- Section of Pediatric Surgery, Department of Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI
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Parikh RM, Ata A, Edwards MJ. A Contemporary Review of Surgical Approach and Outcomes in Pediatric Hypertrophic Pyloric Stenosis. J Surg Res 2023; 285:142-149. [PMID: 36669393 DOI: 10.1016/j.jss.2022.12.034] [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: 09/01/2022] [Revised: 11/02/2022] [Accepted: 12/25/2022] [Indexed: 01/20/2023]
Abstract
INTRODUCTION In order to define optimal resources and outcome standards for infant pyloromyotomy, we sought to perform a contemporary analysis of surgical approach (laparoscopic versus open) and outcomes. METHODS The National Surgical Quality Improvement Project Pediatrics Participant Use File (NSQIP PUF) was queried from 2016 to 2020. Utilization of laparoscopy was trended over time. Complication rates and length of stay were compared by operative approach. RESULTS 9752 pyloromyotomies were included in the analysis. The utilization of laparoscopy steadily increased over the study time period (66% to 79%) and was associated with a shorter operative time. On multivariate regression, the utilization of laparoscopy was associated with a lower risk of overall complications, length of stay, and superficial surgical site infections. Overall complication rates were lower than previously reported (2.02%). The most common complication was superficial infection (1.2%). CONCLUSIONS In facilities reporting to pediatric National Quality Improvement Project, utilization of laparoscopy has steadily increased, and complication rates are lower than previously reported. Complication rates and length of stay were lower with the laparoscopic approach in this contemporary cohort. These results offer benchmarks for quality improvement initiatives. The laparoscopic approach should be standard in facilities performing this procedure.
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Affiliation(s)
| | - Ashar Ata
- Department of Surgery, Albany Medical Center, Albany, New York
| | - Mary J Edwards
- Department of Surgery, Albany Medical Center, Albany, New York.
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Georgeades C, Farazi MR, Gainer H, Flynn-O'Brien KT, Leys CM, Gourlay D, Van Arendonk KJ. Distribution of acute appendicitis care in children: A statewide assessment of the surgeons and facilities providing surgical care. Surgery 2023; 173:765-773. [PMID: 36244816 DOI: 10.1016/j.surg.2022.06.053] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 06/06/2022] [Accepted: 06/21/2022] [Indexed: 01/01/2023]
Abstract
BACKGROUND Pediatric appendicitis is managed by general and pediatric surgeons at both children's hospitals and non-children's hospitals. A statewide assessment of surgeons and facilities providing appendicitis care was performed to identify factors associated with location of surgical care. METHODS Children aged <18 years undergoing appendectomy for appendicitis in Wisconsin from 2018-2020 were identified through the International Classification of Diseases, 10th revision, and Current Procedural Terminology codes using Wisconsin Hospital Association data. Patient residence and hospital locations were used to determine travel distance, rurality, and neighborhood-level socioeconomic status. RESULTS Among 3,604 children with appendicitis, 36.0% and 12.8% had an appendectomy at 2 major children's hospitals and 4 other children's hospitals, respectively, and 51.2% had an appendectomy at 99 non-children's hospitals. Pediatric surgeons performed 76.1% of appendectomies at children's hospitals and 2.9% at non-children's hospitals. Only 32.2% of patients received care at the hospital closest to their homes. Non-children's hospitals disproportionally cared for older, non-Hispanic White, and privately insured children, those with uncomplicated appendicitis, and those living in rural areas, in mid-socioeconomic status neighborhoods, and greater distances from children's hospitals (all P < .001). After multivariable adjustment, receipt of care at children's hospitals was associated with younger age, minority race, complicated appendicitis, shorter distance to children's hospitals, and urban residence. CONCLUSION Over half of surgical care for pediatric appendicitis occurred at non-children's hospitals, especially among older children and those living in rural areas far from children's hospitals. Future work is necessary to determine which children benefit most from care at children's hospitals and which can safely receive care at non-children's hospitals to avoid unnecessary time and resource utilization associated with travel to children's hospitals.
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Affiliation(s)
- Christina Georgeades
- Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI.
| | - Manzur R Farazi
- Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Hailey Gainer
- Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | | | - Charles M Leys
- Division of Pediatric Surgery, Department of Surgery, University of Wisconsin, Madison, WI
| | - David Gourlay
- Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Kyle J Van Arendonk
- Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
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Leonhardt J, Muensterer O, Alsweed A, Schmedding A. Nationwide trends of laparoscopic pyloromyotomy in patients with infantile hypertrophic pyloric stenosis in Germany: A slow path forward. Front Pediatr 2023; 11:1149355. [PMID: 37090925 PMCID: PMC10117636 DOI: 10.3389/fped.2023.1149355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Accepted: 03/13/2023] [Indexed: 04/25/2023] Open
Abstract
Since its introduction, laparoscopic pyloromyotomy (LP), has become increasingly popular in many countries. We have noticed an attenuated trend in Germany. The aim of this study was to analyse the distribution of open and LP in Germany. The national database of administrative claims data of the Institute for the Remuneration System in Hospitals (InEK) was analysed regarding numbers of patients with pyloromyotomy in the years 2019-2021. The German quality reports of the hospitals of 2019 and 2020 were analyzed regarding the number of procedures performed per hospital and pediatric surgical department. A total of 2050 patients underwent pyloromyotomy. The incidence of hypertrophic pylorus stenosis (HPS) was 699 and 657 patients in 2019 and 2021, respectively. Regarding age, 31.1% were admitted before 28 days of age. LP gradually increased from 216 patients (30.9%) in 2019 to 239 patients (36.4%) in 2021. Thirty-three laparoscopic operations (4.8%) were converted to an open approach. In 24 of all patients, there was an injury to the stomach, in 20 patients to the duodenum, needing repair with sutures. Analysis of the quality reports indicated that 44% of pediatric surgical departments performed LP. Although LP has became more prevalent in Germany recently, about two thirds of patients still undergo an open procedure.
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Affiliation(s)
- Johannes Leonhardt
- Department of Pediatric Surgery and Pediatric Urology, Klinikum Braunschweig gGmbH, Braunschweig, Germany
| | - Oliver Muensterer
- Department of Pediatric Surgery, Dr. von Hauner Children's Hospital, LMU Klinikum, Munich, Germany
- Correspondence: Oliver Muensterer
| | - Ahmad Alsweed
- Department of Pediatric Surgery and Pediatric Urology, Klinikum Braunschweig gGmbH, Braunschweig, Germany
| | - Andrea Schmedding
- Department of Pediatric Surgery and PediatricUrology, Goethe University Frankfurt, University Hospital Frankfurt, Frankfurt, Germany
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Disma N, Engelhardt T, Hansen TG, de Graaff JC, Virag K, Habre W. Neonates undergoing pyloric stenosis repair are at increased risk of difficult airway management: secondary analysis of the NEonate and Children audiT of Anaesthesia pRactice IN Europe. Br J Anaesth 2022; 129:734-739. [PMID: 36085092 DOI: 10.1016/j.bja.2022.07.041] [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: 04/27/2022] [Revised: 07/18/2022] [Accepted: 07/19/2022] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND Hypertrophic pyloric stenosis in otherwise healthy neonates frequently requires urgent surgical procedure but anaesthesia care may result in respiratory complications, such as hypoxaemia, pulmonary aspiration of gastric contents, and postoperative apnoea. The primary aim was to study whether or not the incidence of difficult airway management and of hypoxaemia in neonates undergoing pyloric stenosis repair was higher than that in neonates undergoing other surgeries. METHODS Data on neonates and infants undergoing anaesthesia and surgery for pyloric stenosis were extracted from the NEonate and Children audiT of Anesthesia pRactice In Europe (NECTARINE) database, for secondary analysis. RESULTS We identified 310 infants who had anaesthesia for surgery for pyloric stenosis. Difficult airway management (more than two attempts at laryngoscopy) was higher in children with pyloric stenosis when compared with the entire NECTARINE cohort (7.9% [95% confidence interval {CI}, 5.22-11.53] vs 4.4% [95% CI, 1.99-6.58]; relative risk [RR]=1.81 [95% CI, 1.21-2.69]; P=0.004), whereas transient hypoxaemia with oxygen saturation <90% was comparable between the two cohorts. Postoperative complications occurred in 16 children (5.6%) within the 30-day follow-up. No mortality was reported at 30 and 90 days. CONCLUSIONS Children undergoing surgery for pyloric stenosis had a higher incidence of difficult intubation compared with the entire NECTARINE cohort. CLINICAL TRIAL REGISTRATION NCT02350348.
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Affiliation(s)
- Nicola Disma
- Unit for Research and Innovation, Department of Anaesthesia, IRCCS Istituto Giannina Gaslini, Genova, Italy.
| | - Thomas Engelhardt
- Department of Anaesthesia, Montreal Children's Hospital, Montreal, Canada
| | - Tom G Hansen
- Department of Clinical Research - Anaesthesiology, University of Southern Denmark, Odense, Denmark
| | - Jurgen C de Graaff
- Department of Anaesthesiology, Erasmus MC-Sophia Children's Hospital, University Medical Centre, Rotterdam, the Netherlands
| | - Katalin Virag
- Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, University Hospitals of Geneva, Geneva, Switzerland; Unit for Anaesthesiological Research, University of Geneva, Geneva, Switzerland
| | - Walid Habre
- Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, University Hospitals of Geneva, Geneva, Switzerland; Unit for Anaesthesiological Research, University of Geneva, Geneva, Switzerland
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Danko ME, Evans PT, Upperman JS. Current management of pyloric stenosis. Semin Pediatr Surg 2022; 31:151145. [PMID: 35305799 DOI: 10.1016/j.sempedsurg.2022.151145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Development of a Standardized Program for the Collaboration of Adult and Children's Surgeons. J Surg Res 2021; 269:36-43. [PMID: 34517187 DOI: 10.1016/j.jss.2021.07.038] [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: 03/01/2021] [Revised: 07/21/2021] [Accepted: 07/26/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Children's hospitals within larger hospitals (CH/LH) have the specific clinical advantage of easily facilitated collaboration between adult and children's surgeons. These collaborations, which we have termed hybrid surgical offerings (HSOs) are often required for disease processes requiring interventions that fall outside the customary practice of children's surgeons. Formal models to describe or evaluate these practices are lacking. METHODS HSOs within a CH/LH were identified. Principles of systems-engineering were used to develop a standardized model (Children's Hybrid Enhanced Surgical Services [CHESS]) to describe and evaluate HSOs. Face validity was established via unstructured interviews of CH leaders and HSO surgeons. Areas for improved system-wide standardization and programmatic development were identified. RESULTS HSOs were identified in collaboration with adult bariatric, minimally invasive, advanced endoscopic, endocrine, thoracic, and orthopedic trauma surgical services. The CHESS framework encompassed: 1) quality improvement metrics, 2) credentialing and oversight, 3) transitions of care, 4) pediatric family-centered care, 5) maintenance of the cycle of expertise, 6) continuing medical education, 7) scholarship. While HSOs fulfilled the majority of aforementioned programmatic domains across all six HSO-providing services, areas for improvement included maintaining a cycle of expertise (33%), quality improvement metrics (50%), and pediatric family-centered care (66%). Additional noted advantages included faster translation of adult innovation to pediatric care and facilitation of emergency interdisciplinary care. CONCLUSION Formal evaluation of HSOs is necessary to standardize and improve the quality of children's surgical care. Development of a structured framework such as CHESS addresses gaps in quality oversight and provides a basis for performance improvement, patient safety, and programmatic development.
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Abstract
BACKGROUND In 2015, the American College of Surgeons began its Children's Surgery Verification Quality Improvement Program, promulgating standards intended to promote regionalization and improve pediatric surgical care. It was hypothesized that pediatric surgical care was already highly regionalized and concentrated before implementation of the program. This study aimed to demonstrate this by describing the sites and volume of nonambulatory pediatric surgery. METHODS A two-part, retrospective, cross-sectional analysis was performed. First, six all-encounter state inpatient data sets (Arkansas, Florida, Kentucky, Maryland, and New York from the Healthcare Cost and Utilization Project and Massachusetts from the Center for Health Information) were used to evaluate all procedures performed within specific hospitals in 2014. Next, a national sample data set (2016 Kids' Inpatient Database) was used to determine the generalizability of the single state results. All acute care hospital admissions for patients less than 18 yr of age were included to describe the nature and location of all surgical procedures therein by patient age, surgical specialty, procedure type, and hospital service breadth. RESULTS Within the six study states, there were 713 hospitals, of which 635 (89.1%) admitted patients less than 18 yr old, and 516 (72.4%) reported pediatric procedures. Among these, there were 9 specialty hospitals and 39 hospitals with services comparable to independent children's hospitals. Of 153,587 procedures among 1,065,655 pediatric admissions, 127,869 (83.3%) took place within these 48 centers. This fraction decreased with age (89.9% of patients less than 2 yr old and 68.5% of 15- to 17-yr-olds), varied slightly by specialty, and was similar across states. Outside of specialized centers, teenagers accounted for 47.4% of all procedures. Within the national data sample, the concentration was similar: 8.7% (328 of 3,777) of all hospitals admitting children were responsible for 90.1% (793,905 of 881,049) of all procedures, with little regional variation. CONCLUSIONS Before the American College of Surgeons Children's Surgery Verification Quality Improvement Program, the vast majority of pediatric nonambulatory surgeries were already confined to a small subset of high-capability and specialty centers. EDITOR’S PERSPECTIVE
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The impact of regionality and hospital status on mortality associated with non-accidental trauma. Am J Surg 2021; 223:238-242. [PMID: 34274104 DOI: 10.1016/j.amjsurg.2021.06.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 06/12/2021] [Accepted: 06/26/2021] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Non-accidental trauma (NAT) affects 2 per 100,000 children annually in the US and may go unrecognized. The aim of this study to quantify the burden of NAT and to evaluate regional variations in mortality. METHODS The Kids Inpatient Database (2000-2012) was queried for pediatric patients presenting with a diagnosis of NAT. Data was obtained on demographic, clinical and hospital-level characteristics. Primary outcome measure was mortality. Multivariable logistic regression models for age, sex, race/ethnicity, insurance status, income quartile, hospital volume, region (Northeast, South, West and Midwest), teaching status, and injury severity scores. RESULTS NAT represented 1.92% (n = 15,999) of all trauma patients. Mortality rates were 3.98% for patients presenting with NAT. African American children had a higher likelihood of mortality compared to White children (OR[95%CI]:1.35[1.03-1.79]), however, this effect was not statistically significant for patients being treated at designated children's hospitals (OR[95%CI]:1.23(0.78-1.95) and urban facilities (OR[95%CI]:1.30[0.99-1.72]). Statistically significant regional variations in mortality, lost significance for patients treated at designated children's hospitals (p > 0.05). CONCLUSION NAT has devastating consequences and is associated with a high mortality rate. Treatment at designated children's hospitals results in the loss of variation in mortality, resulting in diminished disparities and improved outcomes. These findings align with current trends towards the "regionalization of pediatric health care" and reflects the value of regional transfer centers that are.
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Dexter F, Epstein RH, Rodriguez LI. Decline of Pediatric Ambulatory Surgery Cases Performed at Florida General Hospitals Between 2010 and 2018: An Historical Cohort Study. Anesth Analg 2020; 131:1557-1565. [PMID: 33079879 DOI: 10.1213/ane.0000000000004676] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND In the province of Ontario, nonphysiologically complex surgical procedures have increased at 4 pediatric hospitals with a reciprocal decline among the other (general) hospitals performing pediatric surgery. Given the differences between the Canadian and US health systems, we studied whether a similar shift occurred in the state of Florida and examined the age dependence of the shift. METHODS We used outpatient pediatric surgery data from all nonfederal hospitals, hospital-owned facilities, and independent ambulatory surgery centers in Florida, 2010-2018. Inferential analyses were performed comparing 2010-2011 with 2017-2018. Annual caseloads are reported as cases per workday by dividing by 250 workdays per year. RESULTS Statewide, comparing 2010-2011 with 2017-2018, among children 1-17 years, pediatric hospitals' caseload increased overall by 50.7 cases per workday, overall meaning collectively among all hospitals combined. The caseload at general hospitals and ambulatory surgery centers, combined, decreased by 97.7 cases per workday. The general hospitals performed 54.7 fewer cases per workday. Among the 112 general hospitals, the mean pairwise decline was -0.49 cases per workday (99% confidence interval, -0.87 to -0.10; P < .0001). The changes were due to multiple categories of procedures, not just a few. Comparing 2010-2011 with 2017-2018, among 3 age cohorts (1-5, 6-12, and 13-17 years), the pediatric hospitals, statewide, performed overall 16.2, 15.1, and 19.3 more cases per workday, respectively. The general hospitals and ambulatory surgery centers, combined, performed fewer cases per workday for each cohort: 49.4, 21.4, and 26.9, respectively. The general hospitals overall performed fewer cases per workday for each cohort: 27.3, 12.1, and 15.4, respectively. Among general hospitals, the mean pairwise difference in the declines between patients 1-5 years vs 6-17 years was 0.00 cases per workday (99% confidence interval, -0.13 to +0.14). CONCLUSIONS The decline across all age groups was inconsistent with multiple general hospitals increasing their minimum age threshold for surgical patients because, otherwise, the younger patients would have accounted for a larger share of the decreases in caseload. Pediatric hospitals and their anesthesiologists have greater surgical growth than expected from population demographics. Many general hospitals can expect either needing fewer pediatric anesthesiologists or that their pediatric anesthesiologists, who also care for adults, will have smaller proportions of pediatric patients in their practices.
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Affiliation(s)
- Franklin Dexter
- From the Division of Management Consulting, Department of Anesthesia, University of Iowa, Iowa City, Iowa
| | - Richard H Epstein
- Department of Anesthesiology, Pain Management, and Perioperative Medicine, University of Miami Miller School of Medicine, Miami, Florida
| | - Luis I Rodriguez
- Department of Anesthesiology, Pain Management, and Perioperative Medicine, University of Miami Miller School of Medicine, Miami, Florida
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14
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Cladis FP, Davis PJ, DiNardo JA. Hospitalization Patterns for Inpatient Pediatric Surgery and Procedures in California: The Ground Is Shifting. Anesth Analg 2020; 131:1066-1069. [PMID: 32925325 DOI: 10.1213/ane.0000000000004764] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Franklyn P Cladis
- From the Departments of Anesthesiology, University of Pittsburgh School of Medicine and
| | - Peter J Davis
- Anesthesiology & Pediatrics, University of Pittsburgh Medical Center (UPMC) Children's Hospital of Pittsburgh
| | - James A DiNardo
- Department of Anaesthesia, Harvard Medical School, Boston Children's Hospital
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15
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Knotts CM, Prange EJ, Orminski K, Thompson S, Richmond BK. The Provision of Acute Pediatric Surgical Care by Adult Acute Care General Surgeons : Is There a Learning Curve? Am Surg 2020; 86:1640-1646. [PMID: 32683921 DOI: 10.1177/0003134820933251] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND At our hospital, acute surgical care of children aged 6 and older is managed by adult acute care surgeons. Previously published data from a 10-year experience with this model demonstrated no differences in outcomes when compared with pediatric surgical benchmark data. This study assesses for the effects of a learning curve in the care of pediatric patients by comparing outcomes of patients treated in the first three years with those treated in the last 3 years during a 10-year experience with this model. DESIGN This was a retrospective study of pediatric patients aged 6 and older who underwent an emergent or urgent, nontrauma surgical procedure by a general surgeon. Data was obtained via chart review and descriptive statistics were compared between patients operated on between January 1, 2009-January 1, 2012 and January 1, 2016-January 1, 2019. RESULTS In all, 208 cases were performed in the early cohort and 192 cases in the late cohort. Appendectomy was the most common procedure in both intervals (88% early, 94.8% late). Although there was a significant decrease in open procedures in the later cohort (22.6% vs 4.7%, P < .001), there was no significant change in disease-specific complications or negative appendectomies. No consults to a fellowship-trained pediatric surgeon were required during either time period, although one was available if needed. CONCLUSIONS Our data demonstrated a decrease in the number of open procedures in the later cohort. This may be due to an increased comfort level with pediatric laparoscopy over time. However, no significant changes in outcomes were observed. This study supports that acute care general surgeons can provide comparable care to pediatric patients within this age demographic and that although a learning curve, appears to exist with respect to pediatric laparoscopy, it is insignificant in terms of its effect on overall outcomes.
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Affiliation(s)
- Chelsea M Knotts
- 12355Department of Surgery, West Virginia University/Charleston Division, Charleston, WV, USA
| | - Edward J Prange
- 12355West Virginia University School of Medicine/Charleston Division, Charleston, WV, USA
| | - Krysta Orminski
- 12355West Virginia University School of Medicine/Charleston Division, Charleston, WV, USA
| | - Stephanie Thompson
- 20205Charleston Area Medical Center Health Education and Research Institute, Charleston, WV, USA
| | - Bryan K Richmond
- 12355Department of Surgery, West Virginia University/Charleston Division, Charleston, WV, USA
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16
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Wang KS, Cummings J, Stark A, Houck C, Oldham K, Grant C, Fallat M. Optimizing Resources in Children's Surgical Care: An Update on the American College of Surgeons' Verification Program. Pediatrics 2020; 145:peds.2020-0708. [PMID: 32312909 DOI: 10.1542/peds.2020-0708] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Surgical procedures are performed in the United States in a wide variety of clinical settings and with variation in clinical outcomes. In May 2012, the Task Force for Children's Surgical Care, an ad hoc multidisciplinary group comprising physicians representing specialties relevant to pediatric perioperative care, was convened to generate recommendations to optimize the delivery of children's surgical care. This group generated a white paper detailing the consensus opinions of the involved experts. Following these initial recommendations, the American College of Surgeons (ACS), Children's Hospital Association, and Task Force for Children's Surgical Care, with input from all related perioperative specialties, developed and published specific and detailed resource and quality standards designed to improve children's surgical care (https://www.facs.org/quality-programs/childrens-surgery/childrens-surgery-verification). In 2015, with the endorsement of the American Academy of Pediatrics (https://pediatrics.aappublications.org/content/135/6/e1538), the ACS established a pilot verification program. In January 2017, after completion of the pilot program, the ACS Children's Surgery Verification Quality Improvement Program was officially launched. Verified sites are listed on the program Web site at https://www.facs.org/quality-programs/childrens-surgery/childrens-surgery-verification/centers, and more than 150 are interested in verification. This report provides an update on the ACS Children's Surgery Verification Quality Improvement Program as it continues to evolve.
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Affiliation(s)
- Kasper S Wang
- Division of Pediatric Surgery, Department of Surgery, Keck School of Medicine, University of Southern California and Children's Hospital Los Angeles, Los Angeles, California;
| | | | - Ann Stark
- Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Constance Houck
- Division of Perioperative Anesthesia, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Keith Oldham
- Children's Hospital of Wisconsin, Milwaukee, Wisconsin
| | | | - Mary Fallat
- Department of Surgery, University of Louisville, Louisville, Kentucky
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Muffly MK, Honkanen A, Scheinker D, Wang TNY, Saynina O, Singleton MA, Wang CJ, Sanders L. Hospitalization Patterns for Inpatient Pediatric Surgery and Procedures in California: 2000–2016. Anesth Analg 2019; 131:1070-1079. [DOI: 10.1213/ane.0000000000004552] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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18
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Akhtar-Danesh GG, Doumouras AG, Bos C, Flageole H, Hong D. Factors Associated With Outcomes and Costs After Pediatric Laparoscopic Cholecystectomy. JAMA Surg 2019; 153:551-557. [PMID: 29344632 DOI: 10.1001/jamasurg.2017.5461] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Importance The prevalence of pediatric cholelithiasis is increasing with the epidemic of childhood obesity. With this rise, the outcomes and costs of pediatric laparoscopic cholecystectomy become an important public health and economic concern. Objective To assess patient and health system factors associated with the outcomes and costs after laparoscopic cholecystectomy among Canadian children. Design, Setting, and Participants This was a retrospective, population-based study of children 17 years and younger undergoing laparoscopic cholecystectomy from April 1, 2008, until March 31, 2015. The data source was the Canadian Institute for Health Information. The Canadian Institute for Health Information Discharge Abstract Database includes data from all Canadian hospitals. The analysis was limited to inpatient cholecystectomies. All Canadian children undergoing laparoscopic cholecystectomy were included. Exposure The exposure in this study was laparoscopic cholecystectomy. Main Outcomes and Measures The primary outcome was all-cause morbidity, a composite outcome of any complication that prolonged length of stay by 24 hours or required a second, unplanned procedure. The cost of the index admission was also calculated as a secondary outcome. These outcomes of interest were determined before data analysis. Odds ratios and 95% CIs were estimated using multilevel logistic regression models. Results During the study period, 3519 laparoscopic cholecystectomies were performed; of these, 79.1% (n = 2785) were in girls, and 98.0% (n = 3450) were for gallstone disease. The overall morbidity rate was 3.9% (n = 137). After adjustment, patients with comorbidities were more susceptible to morbidity (odds ratio, 2.68; 95% CI, 1.78-3.86; P < .001). Operations for gallstones were less morbid. High-volume general surgeons had lower morbidity rates compared with low-volume pediatric surgeons (odds ratio, 0.32; 95% CI, 0.12-0.69; P = .005) independent of pediatric volumes. The mean (SD) unadjusted cost of a laparoscopic cholecystectomy was $4115 ($7273). Operative indication, complications, comorbidities, emergency admission, and surgeon volume were associated with cost. Conclusions and Relevance The high-volume nature of adult general surgery translated to lower morbidity and cost after pediatric laparoscopic cholecystectomy, suggesting that adult volume is associated with pediatric outcomes. As the rate of pediatric gallstone disease increases, surgeon volume, rather than specialty training, should be considered when pursuing operative management.
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Affiliation(s)
| | - Aristithes G Doumouras
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada.,Division of General Surgery, Department of Surgery, St Joseph's Healthcare, Hamilton, Ontario, Canada
| | - Cecily Bos
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Helene Flageole
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada.,Division of Pediatric Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Dennis Hong
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada.,Division of General Surgery, Department of Surgery, St Joseph's Healthcare, Hamilton, Ontario, Canada
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19
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Akhtar-Danesh GG, Doumouras AG, Flageole H, Hong D. Geographic and socioeconomic predictors of perforated appendicitis: A national Canadian cohort study. J Pediatr Surg 2019; 54:1804-1808. [PMID: 30482382 DOI: 10.1016/j.jpedsurg.2018.10.065] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2018] [Revised: 10/10/2018] [Accepted: 10/16/2018] [Indexed: 12/28/2022]
Abstract
BACKGROUND/PURPOSE Appendiceal perforation significantly impacts the outcomes of pediatric appendicitis. While socioeconomic status affects perforation risk in the United States, these effects should dissipate in a universal healthcare system. The specific spatial patterns associated with perforation have also never been delineated. This study examined the effect of geography and SES on appendiceal perforation in Canada's universal healthcare system. METHODS Using administrative databases, Canadian children with appendicitis from 2008 to 2015 were identified. Perforation rates were examined based on rurality, distance from treating hospital, and SES. A spatial analysis identified neighborhoods with high perforation rates. Predictors of high perforation clusters were determined using logistic regression. RESULTS Over the study period, 43,055 children with appendicitis were identified. The overall perforation rate was 31.5%. Rural neighborhoods and those >125 km from the treating hospital were more likely to be within a high perforation cluster (OR 2.39, 95%CI 1.31-4. 02, p = 0.001; and OR 2.55, 95%CI 1.35-4.47, p = 0.001, respectively). Children in high perforation clusters were more likely to suffer complications. SES was not associated with perforation rates. CONCLUSIONS In this population-based study, appendiceal perforation was not a function of SES, but a spatial phenomenon. These findings highlight disparities in access to surgical care in Canada. LEVEL OF EVIDENCE Prognosis study, level II.
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Affiliation(s)
- Gileh-Gol Akhtar-Danesh
- Department of Surgery, McMaster University, 1280 Main Street West, Hamilton, Ontario, L8S 4L8, Canada.
| | - Aristithes G Doumouras
- Department of Surgery, McMaster University, 1280 Main Street West, Hamilton, Ontario, L8S 4L8, Canada; Division of General Surgery, St. Joseph's Healthcare, 50 Charlton Avenue East, Hamilton, Ontario, L8N 4A6, Canada.
| | - Helene Flageole
- Department of Surgery, McMaster University, 1280 Main Street West, Hamilton, Ontario, L8S 4L8, Canada; Division of Pediatric Surgery, McMaster University, 1280 Main Street West, Hamilton, Ontario, L8S 4L8, Canada.
| | - Dennis Hong
- Department of Surgery, McMaster University, 1280 Main Street West, Hamilton, Ontario, L8S 4L8, Canada; Division of General Surgery, St. Joseph's Healthcare, 50 Charlton Avenue East, Hamilton, Ontario, L8N 4A6, Canada.
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20
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Abstract
PURPOSE OF REVIEW Rapid advancement in the field of pediatric surgery has resulted in unprecedented opportunities to advance the care of children. However, assuring that the highest quality, most appropriate care is available to all pediatric patients remains challenging. Regionalization of care has been proposed as a means of obtaining this critical goal. In this review, we discuss the ethical challenges associated with regionalization of pediatric surgical care. RECENT FINDINGS Regionalization of pediatric surgical care is associated with improved patient outcomes. Over half of pediatric surgeons favor regionalization of care. Despite these findings, regionalization of care may be associated with inequitable distribution of resources, financial and emotional burdens for patients and families, and surgeon dissatisfaction and technical decline. SUMMARY Regionalization of pediatric surgical care is fraught with complex ethical issues. Development of a system of pediatric surgery networks may offer a solution to these challenges.
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21
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Sakai-Bizmark R, Mena LA, Kumamaru H, Kawachi I, Marr EH, Webber EJ, Seo HH, Friedlander SIM, Chang RKR. Impact of pediatric cardiac surgery regionalization on health care utilization and mortality. Health Serv Res 2019; 54:890-901. [PMID: 30916392 DOI: 10.1111/1475-6773.13137] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE Regionalization directs patients to high-volume hospitals for specialized care. We investigated regionalization trends and outcomes in pediatric cardiac surgery. DATA SOURCES/STUDY SETTING Statewide inpatient data from eleven states between 2000 and 2012. STUDY DESIGN Mortality, length of stay (LOS), and cost were assessed using multivariable hierarchical regression with state and year fixed effects. Primary predictor was hospital case-volume, categorized into low-, medium-, and high-volume tertiles. DATA COLLECTION/EXTRACTION METHODS We used Risk Adjustment for Congenital Heart Surgery-1 (RACHS-1) to select pediatric cardiac surgery discharges. PRINCIPAL FINDINGS In total, 2841 (8.5 percent), 8348 (25.1 percent), and 22 099 (66.4 percent) patients underwent heart surgeries in low-, medium-, and high-volume hospitals. Mortality decreased over time, but remained higher in low- and medium-volume hospitals. High-volume hospitals had lower odds of mortality and cost than low-volume hospitals (odds ratio [OR] 0.59, P < 0.01, and relative risk [RR] 0.91, P < 0.01, respectively). LOS was longer for high- and medium-volume hospitals, compared to low-volume hospitals (high-volume: RR 1.18, P < 0.01; medium-volume: RR 1.05, P < 0.01). CONCLUSIONS Regionalization reduced mortality and cost, indicating fewer complications, but paradoxically increased LOS. Further research is needed to explore the full impact on health care utilization.
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Affiliation(s)
- Rie Sakai-Bizmark
- Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, California.,Department of Pediatrics, Harbor-UCLA Medical Center, Torrance, California.,The David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California
| | - Laurie A Mena
- Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, California
| | - Hiraku Kumamaru
- Department of Healthcare Quality Assessment, The University of Tokyo School of Medicine, Tokyo, Japan
| | - Ichiro Kawachi
- Department of Social and Behavioral Sciences, Harvard T.H. Chang School of Public Health, Boston, Massachusetts
| | - Emily H Marr
- Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, California
| | - Eliza J Webber
- Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, California
| | - Hyun H Seo
- Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, California.,Anderson School of Management, University of California at Los Angeles, Los Angeles, California
| | - Scott I M Friedlander
- Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, California
| | - Ruey-Kang R Chang
- Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, California.,Department of Pediatrics, Harbor-UCLA Medical Center, Torrance, California.,The David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California
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22
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Effects of Hospital Volume on Patient Outcomes and Costs in Infants With Pyloric Stenosis. J Surg Res 2018; 233:65-73. [PMID: 30502289 DOI: 10.1016/j.jss.2018.07.033] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 05/27/2018] [Accepted: 07/11/2018] [Indexed: 11/22/2022]
Abstract
BACKGROUND There is a well-established relationship between surgical volume and outcomes after complex pediatric operations. However, this relationship remains unclear for common pediatric procedures. The aim of our study was to investigate the effect of hospital volume on outcomes after hypertrophic pyloric stenosis (HPS). METHODS The Kid's Inpatient Database (2003-2012) was queried for patients with congenital HPS, who underwent pyloromyotomy. Hospitals were stratified based on case volume. Low-volume hospitals performed the lowest quartile of pyloromyotomies per year and high-volume hospitals managed the highest quartile. Outcomes included complications, mortality, length of stay (LOS), and cost. RESULTS Overall, 2137 hospitals performed 51,792 pyloromyotomies. The majority were low-volume hospitals (n = 1806). High-volume hospitals comprised mostly children's hospitals (68%) and teaching hospitals (96.1%). The overall mortality rate was 0.1% and median LOS was 2 d. High-volume hospitals had lower overall complications (1.8% versus 2.5%, P < 0.01) and fewer patients with prolonged LOS (17.0% versus 23.5%, P < 0.01) but had similar rates of individual complications, similar mortality, and equivalent median LOS as low-volume hospitals. High-volume hospitals also had higher costs by $1132 per patient ($5494 versus $4362, P < 0.01). Regional variations in outcomes and costs exist with higher complication rates in the West and lower costs in the South. There was no association between mortality or LOS with hospital volume or region. CONCLUSIONS Patients with pyloric stenosis treated at high-volume hospitals had no clinically significant difference in outcomes despite having higher costs. Although high-volume hospitals offer improved outcomes after complex pediatric surgeries, they may not provide a significant advantage over low-volume hospitals in managing common pediatric procedures, such as pyloromyotomy for congenital HPS.
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Abstract
IMPORTANCE Hospital care for children is becoming more concentrated, with interhospital transfer occurring more frequently even for common conditions. Condition-specific analysis is required to determine the value, costs, and consequences of this trend. OBJECTIVES To describe the capabilities of transferring and receiving hospitals and to determine how often children transferred after an initial diagnosis of abdominal pain or appendicitis require higher levels of care. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort analysis using the 2 most recent available inpatient and emergency department administrative data sets from all acute care hospitals in California from 2010 to 2011 and Florida, Massachusetts, and New York from 2013 to 2014. Data were analyzed between February and June 2018. All patients younger than 18 years with a primary diagnosis of abdominal pain or appendicitis who underwent an interhospital transfer and whose care could be matched through unique identifiers were included. MAIN OUTCOMES AND MEASURES Outcomes after hospital transfers, classified into encounters with major surgical procedures, imaging diagnostics, and no major procedures. Pediatric Hospital Capability Index of transferring and receiving hospitals. RESULTS There were 465 143 pediatric hospital encounters for abdominal pain and appendicitis, including 53 517 inpatient admissions and 15 275 transfers. Among them, 4469 could be matched to encounters in receiving hospitals. The median (interquartile range) age of this cohort was 10 (7-14) years, with 54.8% female (2449 patients), 40.9% male (1830 patients), and 4.3% unreported sex (190 patients). The increase in capability at the receiving hospital compared with the transferring hospital was large (median [interquartile range] change in Pediatric Hospital Capability Index score, 0.70 [0.54-0.82]), with 9.2% of hospitals (57) with very high capability (Pediatric Hospital Capability Index score >0.77) receiving 80.8% of the total transfers (3610). Diagnostic imaging was undertaken in the care of 710 transferred patients (15.9%) and invasive procedures were performed in 2421 patients (54.2%), including 2153 appendectomies. No imaging or surgery was required in the care of 1338 transfers (29.9%). CONCLUSIONS AND RELEVANCE In this study, interfacility transfers of patients with appendicitis and abdominal pain were concentrated toward high-capability hospitals, and about 30% of patients were released without apparent intervention. These findings suggest an opportunity for improving care and decreasing cost through better interfacility coordination, such as standardized management protocols and telemedicine with high-capability hospitals. Further research is needed to identify similar opportunities among other common conditions.
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Affiliation(s)
- Urbano L. França
- Division of Critical Care, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Michael L. McManus
- Division of Critical Care, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
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Trauma surgeon performance of appendectomy in 5-year- to 10-year-old children is safe and decreases length of hospital stay. J Trauma Acute Care Surg 2018; 85:118-121. [PMID: 29554038 DOI: 10.1097/ta.0000000000001902] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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25
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Abstract
Infantile hypertrophic pyloric stenosis (IHPS) is the most common gastrointestinal disease among infants. IHPS occurs as an isolated condition or together with other congenital anomalies. Association with genetic and environmental factors, bottle feeding, younger maternal age, maternal smoking, and erythromycin administration in the first two weeks of life has been shown. Familial aggregation has been described and a family history is seen in 47.9 percent of siblings. Infants typically present with projectile vomiting associated with symptoms of failure to thrive. An olive-like mass palpable in the right upper abdominal quadrant is being reported less frequently because of earlier diagnosis by ultrasound. IHPS is generally corrected through laparoscopic pyloromyotomy. Endoscopic pyloric balloon dilation is a novel alternative. Further studies on different populations, the general population, and familial segregation to determine the prevalence, influence, and mode of familial aggregation and correlation with environmental factors are needed to determine the etiology of IHPS.
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26
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Cairo SB, Harmon CM, Rothstein DH. Minimally invasive surgical exposure among US and Canadian pediatric surgery trainees, 2004-2016. J Surg Res 2018; 231:179-185. [PMID: 30278927 DOI: 10.1016/j.jss.2018.05.053] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 05/02/2018] [Accepted: 05/24/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Minimally invasive pediatric surgery has increased in breadth and complexity over the past several decades, with little data on minimally invasive surgery (MIS) training in US and Canadian pediatric surgery fellowship programs. METHODS We performed a time series analysis of Accreditation Council for Graduate Medical Education pediatric surgery fellow case logs from 2003 to 2016. Proportions of cases performed in an MIS fashion as well as per-fellow MIS case averages were recorded over time. RESULTS There was a 30.9% increase in average number of MIS cases per fellow over the study time period. Twenty-three recorded procedures included MIS and open options (17 abdominal, three thoracic, and three genitourinary). The proportion of cases performed using a minimally invasive approach increased by an average of 29.0%, 14.6%, and 47.0% for each of these categories, respectively. Significant variability was observed in specific cases such as laparoscopic and open inguinal hernias, ranging from 0 to 85 and nine to 152 per trainee, respectively, in the final year of data collection. When examining pyloromyotomy, a high-volume procedure with a known increase in the MIS approach, the proportion of cases performed MIS increased by 83.3%. The minimum and maximum number of cases per fellow recorded ranged from 0 to 114 during the eight years in which MIS pyloromyotomy was recorded. CONCLUSIONS MIS case exposure among graduating US and Canadian pediatric survey fellows increased substantially during the study period. More granular data, however, are needed to better define the current operative experience and criteria for determination of competency in advanced MIS.
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Affiliation(s)
- Sarah B Cairo
- Department of Pediatric Surgery, John R. Oishei Children's Hospital of Buffalo, Buffalo, New York.
| | - Carroll M Harmon
- Department of Pediatric Surgery, John R. Oishei Children's Hospital of Buffalo, Buffalo, New York; Department of Surgery, State University of New York, University at Buffalo, Buffalo, New York
| | - David H Rothstein
- Department of Pediatric Surgery, John R. Oishei Children's Hospital of Buffalo, Buffalo, New York; Department of Surgery, State University of New York, University at Buffalo, Buffalo, New York
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27
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Baxter KJ, Gale BF, Travers CD, Heiss KF, Raval MV. Ramifications of the Children's Surgery Verification Program for Patients and Hospitals. J Am Coll Surg 2018; 226:917-924.e1. [DOI: 10.1016/j.jamcollsurg.2018.02.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Revised: 02/05/2018] [Accepted: 02/06/2018] [Indexed: 10/18/2022]
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Litz CN, Ciesla DJ, Danielson PD, Chandler NM. Effect of hospital type on the treatment of acute appendicitis in teenagers. J Pediatr Surg 2018; 53:446-448. [PMID: 28408075 DOI: 10.1016/j.jpedsurg.2017.03.062] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Accepted: 03/30/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Teenagers receive appendicitis care at both adult and pediatric facilities. The purpose of this study was to evaluate outcomes following treatment of acute appendicitis in teenagers based on the type of hospital facility. METHODS Patients aged 13-17years with acute appendicitis who were discharged from acute care hospitals from 2009 to 2014 were identified using a statewide discharge dataset. Hospitals were classified as pediatric or adult and outcomes were compared. RESULTS There were 5585 patients treated in adult hospitals and 1625 in pediatric hospitals. Fewer patients at adult hospitals had complicated appendicitis (20.4% vs. 33.0%, p<0.01). Open appendectomy occurred more often in adult hospitals compared to pediatric hospitals (12.6% vs. 6.0%, p<0.01). Pediatric hospitals had higher rates of non-operative management (10% vs. 3.4%, p<0.01) and percutaneous drain placement (1.2% vs. 0.4%, p<0.01). Postoperative complication rates did not significantly differ between hospital types. CONCLUSION Most teenagers undergo appendectomy at adult facilities; however, a greater proportion of younger patients and patients with complicated appendicitis is treated at pediatric hospitals. Treatment at a freestanding children's hospital results in lower rates of open procedures and no difference in complications. Opportunities may exist to standardize care across treating facilities to optimize outcomes and resource use. TYPE OF STUDY Prognosis study. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Cristen N Litz
- Johns Hopkins All, Children's Hospital, Outpatient Care Center, 601 5(th) Street South, Dept 70-6600, 3(rd) Floor, Saint Petersburg, FL 33701.
| | - David J Ciesla
- University of South Florida, Morsani College of Medicine, 1 Tampa General Circle, G417, Tampa, FL 33606.
| | - Paul D Danielson
- Johns Hopkins All, Children's Hospital, Outpatient Care Center, 601 5(th) Street South, Dept 70-6600, 3(rd) Floor, Saint Petersburg, FL 33701.
| | - Nicole M Chandler
- Johns Hopkins All, Children's Hospital, Outpatient Care Center, 601 5(th) Street South, Dept 70-6600, 3(rd) Floor, Saint Petersburg, FL 33701.
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Understanding the relationship between hospital volume and patient outcomes for infants with gastroschisis. J Pediatr Surg 2017; 52:1977-1980. [PMID: 28947327 DOI: 10.1016/j.jpedsurg.2017.08.065] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Accepted: 08/28/2017] [Indexed: 11/20/2022]
Abstract
BACKGROUND For many surgical operations, there is a well-established relationship between surgical volume and outcome. We investigated whether this relationship exists for infants with gastroschisis. METHODS Using the Kids' Inpatient Database for years 2003, 2006, 2009, and 2012, we identified all patients undergoing gastroschisis repair. Controlling for patient characteristics and complexity of disease (comorbid intestinal atresia/perforation, necrotizing enterocolitis, and respiratory distress syndrome), we compared surgical outcomes (mortality, length of stay, and incidence of TPN cholestasis) by hospital volume based on quartile for gastroschisis cases treated per year. RESULTS We identified 7769 patients treated at 743 hospitals. The majority of hospitals were low-volume (n=445), while only 49 were high-volume. The overall mortality rate was 4.3%, and the median length of stay was 34days. Adjusting for clinical and demographic characteristics, patients treated at high-volume hospitals had similar rates of TPN cholestasis and similar mortality rates, but a higher chance for a prolonged length of stay compared to those treated at low-volume hospitals. CONCLUSIONS Using national data, we found that gastroschisis patients treated at high-volume hospitals did not have improved outcomes. The benefits of high-volume hospitals, which seem to be important for complex pediatric surgery, may not apply to treatment of gastroschisis. LEVEL OF EVIDENCE Level III Retrospective Study.
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Abstract
High salaries indicate a demand for pediatric surgeons in excess of the supply, despite only a slight growth in the pediatric-age population and a sharp increase in numbers of trainees. Top-level neonatal intensive care units require 24-hour-7-day pediatric surgical availability, so hospitals are willing to pay surgeons a premium and engage high-priced locum tenens surgeons to fill vacancies in coverage. With increased supply comes an erosion of the numbers of cases performed by trainees and surgeons in practice. Caseloads may be inadequate to gain expertise and maintain skills. A quality initiative sponsored by the American College of Surgeons and the American Pediatric Surgical Association will discourage underresourced community facilities and surgeons without specialty training from performing operations on children, mostly common conditions such as appendicitis. This will further increase demand for specialty-trained practitioners. Receiving less attention are considerations of value, the ratio of quality per dollar cost. Cost concerns, paramount among buyers of health care (businesses, insurance companies, and governmental health agencies), will prefer community hospitals that have lower cost structures than specialty children's facilities. Less recognized are the costs to families, who for a myriad of reasons would prefer closer alternatives. Cost considerations support providing pediatric surgical services in local facilities. Quality considerations may be addressed by a tiered system where top centers would care for conditions that require technical expertise and advanced modalities. Evidence indicates that pediatric surgeons already direct such cases to more specialized centers.
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Affiliation(s)
- Don K. Nakayama
- Department of Surgery, Florida International University, Sacred Heart Medical Group, Pensacola, Florida
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The American College of Surgeons Children's Surgery Verification and Quality Improvement Program. Curr Opin Anaesthesiol 2017; 30:376-382. [DOI: 10.1097/aco.0000000000000467] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Ednie AC, Amram O, Schuurman N, Yanchar NL. Comparing pyloromyotomy outcomes across Canada. J Pediatr Surg 2017; 52:739-743. [PMID: 28238307 DOI: 10.1016/j.jpedsurg.2017.01.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Accepted: 01/23/2017] [Indexed: 11/15/2022]
Abstract
BACKGROUND Changing patterns of referral and management of hypertrophic pyloric stenosis (HPS) in North America have recently been described. Comfort with perioperative management, anesthesia, and corrective surgery have been cited as reasons for these changes. Our primary objective was to assess pyloromyotomy outcomes between different hospital types across Canada. The secondary objective was to geospatially map all pyloromyotomies to identify regions of higher HPS incidence across Canada. METHODS Data of all pyloromyotomies done between 2011 and 2013 were acquired from Canadian Institute for Health Information (CIHI). Complication rates and length of hospital stay (LOS) were analyzed. Postal codes for each patient were used to geospatially map regions of higher HPS incidence. RESULTS A total of 1261 pyloromyotomies were assessed. There was no difference in LOS or complication rates between different hospital types or surgeon group. Open pyloromyotomies were done in 75% of the cases. Several regions of higher HPS incidence were identified across Canada. CONCLUSION This study found no difference in complication rate or LOS stay between hospital type and surgeon type across Canada. This may reflect a previously identified referral trend in the United States towards pediatric centers. Several regions of higher HPS incidence were identified, and may aid in identifying genetic elements causing HPS. LEVEL OF EVIDENCE 2c.
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Affiliation(s)
- Alexander C Ednie
- Dalhousie University, Division of General Surgery, QEII Health Sciences Centre, 8-813 VG Site, 1276 South Park Street, Halifax, NS, B3H 2Y9, Canada.
| | - Ofer Amram
- Simon Fraser University, Department of Geography, 8888 University Drive, Burnaby, BC, V5A 1S6, Canada
| | - Nadine Schuurman
- Simon Fraser University, Department of Geography, 8888 University Drive, Burnaby, BC, V5A 1S6, Canada
| | - Natalie L Yanchar
- Dalhousie University, Division of General Surgery, QEII Health Sciences Centre, 8-813 VG Site, 1276 South Park Street, Halifax, NS, B3H 2Y9, Canada; IWK Health Centre, Division of Pediatric Surgery, 5980 University Ave, Halifax, NS, B3K 6R8, Canada
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Ednie AC, Amram O, Creaser JC, Schuurman N, Leclerc S, Yanchar N. Hypertrophic pyloric stenosis in the Maritimes: examining the waves of change over time. Can J Surg 2017; 59:383-390. [PMID: 27669400 DOI: 10.1503/cjs.002816] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Changing patterns of referral and management of pediatric surgical conditions, including hypertrophic pyloric stenosis (HPS), have recently been described and often relate to comfort with early nonoperative management, anesthesia and corrective surgery. Travelling distance required for treatment at pediatric centres can also be burdensome for families. We assessed referral patterns for HPS in the maritime provinces of Canada over 10 years to quantify the burden on families travelling for surgical care. METHODS We reviewed the charts of all patients with HPS in the Maritimes. Length of hospital stay (LOS) and complication rates were analyzed in regards to resuscitation and management at a pediatric centre and/or peripheral centres. We used postal codes for each patient to track distance travelled for management. RESULTS We assessed 751 cases of HPS. During the study period (Jan. 1, 2001-Dec. 31, 2010), referral to pediatric centres increased from 49% to 71%. Postoperative complications were 2.5-fold higher in peripheral centres. Infants referred to pediatric centres were 78% less likely to have an LOS longer than 3 days. Laparoscopic pyloromyotomy, which was performed only in pediatric centres, was associated with a shorter postoperative LOS. CONCLUSION Our study supports the current literature demonstrating improved outcomes, shorter overall LOS and decreased risk of complications when infants with HPS are treated in pediatric centres. This should be considered when planning access to pediatric surgical resources.
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Affiliation(s)
- Alexander C Ednie
- From the Department of General Surgery, Dalhousie University, Halifax, NS (Ednie); the Department of Medicine, Division of AIDS, University of British Columbia, Vancouver, BC (Amram); the Epidemiology and Population Health Program, BC Centre for Excellence in HIV/AIDS, Vancouver, BC (Amram); the University of British Columbia, Vancouver, BC (Creaser); the Department of Geography, Simon Fraser University, Vancouver, BC (Schuurman); the Department of Pediatric Surgery, Centre Hospitalier Universitaire de Queébec, Québec, Que. (Leclerc); the Departments of Surgery and Community Health and Epidemiology, Dalhousie University, Halifax, NS (Yanchar); and the Department of Pediatric General Surgery, IWK Health Centre, Halifax, NS (Yanchar)
| | - Ofer Amram
- From the Department of General Surgery, Dalhousie University, Halifax, NS (Ednie); the Department of Medicine, Division of AIDS, University of British Columbia, Vancouver, BC (Amram); the Epidemiology and Population Health Program, BC Centre for Excellence in HIV/AIDS, Vancouver, BC (Amram); the University of British Columbia, Vancouver, BC (Creaser); the Department of Geography, Simon Fraser University, Vancouver, BC (Schuurman); the Department of Pediatric Surgery, Centre Hospitalier Universitaire de Queébec, Québec, Que. (Leclerc); the Departments of Surgery and Community Health and Epidemiology, Dalhousie University, Halifax, NS (Yanchar); and the Department of Pediatric General Surgery, IWK Health Centre, Halifax, NS (Yanchar)
| | - Jenna Colleen Creaser
- From the Department of General Surgery, Dalhousie University, Halifax, NS (Ednie); the Department of Medicine, Division of AIDS, University of British Columbia, Vancouver, BC (Amram); the Epidemiology and Population Health Program, BC Centre for Excellence in HIV/AIDS, Vancouver, BC (Amram); the University of British Columbia, Vancouver, BC (Creaser); the Department of Geography, Simon Fraser University, Vancouver, BC (Schuurman); the Department of Pediatric Surgery, Centre Hospitalier Universitaire de Queébec, Québec, Que. (Leclerc); the Departments of Surgery and Community Health and Epidemiology, Dalhousie University, Halifax, NS (Yanchar); and the Department of Pediatric General Surgery, IWK Health Centre, Halifax, NS (Yanchar)
| | - Nadine Schuurman
- From the Department of General Surgery, Dalhousie University, Halifax, NS (Ednie); the Department of Medicine, Division of AIDS, University of British Columbia, Vancouver, BC (Amram); the Epidemiology and Population Health Program, BC Centre for Excellence in HIV/AIDS, Vancouver, BC (Amram); the University of British Columbia, Vancouver, BC (Creaser); the Department of Geography, Simon Fraser University, Vancouver, BC (Schuurman); the Department of Pediatric Surgery, Centre Hospitalier Universitaire de Queébec, Québec, Que. (Leclerc); the Departments of Surgery and Community Health and Epidemiology, Dalhousie University, Halifax, NS (Yanchar); and the Department of Pediatric General Surgery, IWK Health Centre, Halifax, NS (Yanchar)
| | - Suzanne Leclerc
- From the Department of General Surgery, Dalhousie University, Halifax, NS (Ednie); the Department of Medicine, Division of AIDS, University of British Columbia, Vancouver, BC (Amram); the Epidemiology and Population Health Program, BC Centre for Excellence in HIV/AIDS, Vancouver, BC (Amram); the University of British Columbia, Vancouver, BC (Creaser); the Department of Geography, Simon Fraser University, Vancouver, BC (Schuurman); the Department of Pediatric Surgery, Centre Hospitalier Universitaire de Queébec, Québec, Que. (Leclerc); the Departments of Surgery and Community Health and Epidemiology, Dalhousie University, Halifax, NS (Yanchar); and the Department of Pediatric General Surgery, IWK Health Centre, Halifax, NS (Yanchar)
| | - Natalie Yanchar
- From the Department of General Surgery, Dalhousie University, Halifax, NS (Ednie); the Department of Medicine, Division of AIDS, University of British Columbia, Vancouver, BC (Amram); the Epidemiology and Population Health Program, BC Centre for Excellence in HIV/AIDS, Vancouver, BC (Amram); the University of British Columbia, Vancouver, BC (Creaser); the Department of Geography, Simon Fraser University, Vancouver, BC (Schuurman); the Department of Pediatric Surgery, Centre Hospitalier Universitaire de Queébec, Québec, Que. (Leclerc); the Departments of Surgery and Community Health and Epidemiology, Dalhousie University, Halifax, NS (Yanchar); and the Department of Pediatric General Surgery, IWK Health Centre, Halifax, NS (Yanchar)
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Ehrlich PF, Hamilton TE, Gow K, Barnhart D, Ferrer F, Kandel J, Glick R, Dasgupta R, Naranjo A, He Y, Perlman EJ, Kalapurakal JA, Khanna G, Dome JS, Geller J, Mullen E. Surgical protocol violations in children with renal tumors provides an opportunity to improve pediatric cancer care: a report from the Children's Oncology Group. Pediatr Blood Cancer 2016; 63:1905-10. [PMID: 27229358 PMCID: PMC5030129 DOI: 10.1002/pbc.26083] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Revised: 03/31/2016] [Accepted: 04/26/2016] [Indexed: 01/07/2023]
Abstract
BACKGROUND The purpose of this study was to evaluate the frequency and characteristics of surgical protocol violations (SPVs) among children undergoing surgery for renal tumors who were enrolled on the Children's Oncology Group (COG) renal tumor biology and classification study AREN03B2. METHODS AREN03B2 was opened in February 2006, and as on March 31, 2013, there were 3,664 eligible patients. The surgical review forms for 3,536 patients with unilateral disease were centrally reviewed for SPVs. The frequency, type, number of violations, institutional prevalence, and quartiles for SPVs were assessed. RESULTS Of the 3,536 patients, there were a total of 505 with at least one SPV (564 total SPVs reported), for an overall incidence of 14.28%. The types of SPVs included a lack of lymph node sampling in 365 (64.7%), avoidable spill in 61 (10.8%), biopsy immediately before nephrectomy in 89 (15.8%), an incorrect abdominal incision in 32 (5.7%), and unnecessary resection of organs in 17 (3.0%). The SPVs occurred in 163 of 215 participating institutions (75.8%). For centers with at least one SPV, the mean number of SPVs reported was 3.10 ± 2.39 (mean ± standard deviation). The incidence of protocol violation per institution ranged from 0 to 67%. Centers with an average of ≤1 case/year had an incidence of SPVs of 12.2 ± 3.8%, those with an average of >1 to <4 cases/year had an incidence of SPVs of 16.4 ± 3.6%, and those with an average of ≥4 cases/year had an incidence of SPVs of 12.6 ± 5.5% (P > 0.05). CONCLUSIONS SPVs that potentially result in additional exposure to chemotherapy and radiation therapy are not uncommon in children undergoing resection of renal malignancies.
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Affiliation(s)
| | - Thomas E. Hamilton
- Dana Farber Cancer Institute, Boston Children's Hospital, Boston, MA, USA
| | - Kenneth Gow
- Seattle Children's Hospital, Seattle, WA, USA
| | | | | | - Jessica Kandel
- Comer Children's Hospital University of Chicago, Chicago IL, USA
| | - Richard Glick
- Steven and Alexandra Cohen Medical Center of New York, New York, NY, USA
| | | | - Arlene Naranjo
- Children's Oncology Group (COG) Statistics and Data Center (SDC), University of Florida, Gainesville, FL, USA
| | - Ying He
- Clarkson University, Potsdam NY, USA
| | - Elizabeth J. Perlman
- Luire Children's Hospital Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - John A. Kalapurakal
- Luire Children's Hospital Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | | | | | - James Geller
- Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - Elizabeth Mullen
- Dana Farber Cancer Institute, Boston Children's Hospital, Boston, MA, USA
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Bucher BT, Duggan EM, Grubb PH, France DJ, Lally KP, Blakely ML. Does the American College of Surgeons National Surgical Quality Improvement Program pediatric provide actionable quality improvement data for surgical neonates? J Pediatr Surg 2016; 51:1440-4. [PMID: 27046303 DOI: 10.1016/j.jpedsurg.2016.02.084] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Revised: 02/23/2016] [Accepted: 02/24/2016] [Indexed: 12/23/2022]
Abstract
BACKGROUND/PURPOSE The purpose of this project was to examine the American College of Surgeons National Surgical Quality Improvement Program Pediatric (ACSNSQIP-P) Participant Use File (PUF) to compare risk-adjusted outcomes of neonates versus other pediatric surgical patients. METHODS In the ACS-NSQIP-P 2012-2013 PUF, patients were classified as preterm neonate, term neonate, or nonneonate at the time of surgery. The primary outcomes were 30-day mortality and composite morbidity. Patient characteristics significantly associated with the primary outcomes were used to build a multivariate logistic regression model. RESULTS The overall 30-day mortality rate for preterm neonates, term neonate, and nonneonates was 4.9%, 2.0%, 0.1%, respectively (p<0.0001). The overall 30-day morbidity rate for preterm neonates, term neonates, and nonneonates was 27.0%, 17.4%, 6.4%, respectively (p<0.0001). After adjustment for preoperative and operative risk factors, both preterm (adjusted odds ratio, 95% CI: 2.0, 1.4-3.0) and term neonates (aOR, 95% CI: 1.9, 1.2-3.1) had a significantly increased odds of 30-day mortality compared to nonneonates. CONCLUSION Surgical neonates are a cohort who are particularity susceptible to postoperative morbidity and mortality after adjusting for preoperative and operative risk factors. Collaborative efforts focusing on surgical neonates are needed to understand the unique characteristics of this cohort and identify the areas where the morbidity and mortality can be improved.
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Affiliation(s)
- Brian T Bucher
- Division of Pediatric Surgery, Department of Surgery, University of Utah School of Medicine, 100 North Mario Capecchi Drive, Suite #3800, Salt Lake City, UT 84113-1103, USA.
| | - Eileen M Duggan
- Department of Pediatric Surgery, Section of Surgical Sciences, Vanderbilt University School of Medicine, 7100 Doctors' Office Tower, 2200 Children's Way, Nashville, TN 37232, USA
| | - Peter H Grubb
- Division of Neonatology, Department of Pediatrics, Vanderbilt University School of Medicine, 11111 Doctors' Office Tower, 2200 Children's Way, Nashville, TN 37232, USA
| | - Daniel J France
- Center for Research and Innovation in Systems Safety, Department of Anesthesiology, Vanderbilt University School of Medicine, 2301 Vanderbilt University Hospital, 1211 Medical Center Drive, Nashville, TN 37232, USA
| | - Kevin P Lally
- Department of Pediatric Surgery, UT Health Medical School and Children's Memorial Hermann Hospital, 6431 Fannin Street, Suite 5.258, Houston, TX 77030, USA
| | - Martin L Blakely
- Department of Pediatric Surgery, Section of Surgical Sciences, Vanderbilt University School of Medicine, 7100 Doctors' Office Tower, 2200 Children's Way, Nashville, TN 37232, USA
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Abstract
Hypertrophic pyloric stenosis is a common surgical cause of vomiting in infants. Following appropriate fluid resuscitation, the mainstay of treatment is pyloromyotomy. This article reviews the aetiology and pathophysiology of hypertrophic pyloric stenosis, its clinical presentation, the role of imaging, the preoperative and postoperative management, current surgical approaches and non-surgical treatment options. Contemporary postoperative feeding regimens, outcomes and complications are also discussed.
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Affiliation(s)
- Matthew Jobson
- Department of Paediatric Surgery and Urology, Southampton Children's Hospital, Tremona Rd, Southampton SO16 6YD, UK
| | - Nigel J Hall
- Department of Paediatric Surgery and Urology, Southampton Children's Hospital, Tremona Rd, Southampton SO16 6YD, UK; Faculty of Medicine, University of Southampton, Southampton, UK.
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Arca MJ, Goldin AB, Oldham KT. Optimization of care for the pediatric surgical patient: Why now? Semin Pediatr Surg 2015; 24:311-4. [PMID: 26653166 DOI: 10.1053/j.sempedsurg.2015.08.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
In 2015, the American College of Surgeons (ACS) has begun to verify hospitals and ambulatory centers which meet consensus based optimal resource standards as "Children׳s Surgical Centers." The intent is to identify children-specific resources available within an institution and using a stratification system similar to the ACS Trauma Program match these to the needs of infants and children with surgical problems. This review briefly summarizes the history, supporting data and processes which drove this initiative.
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Affiliation(s)
- Marjorie J Arca
- Division of Pediatric Surgery, Medical College of Wisconsin, Milwaukee, WI; Children׳s Hospital of Wisconsin, Milwaukee, WI.
| | - Adam B Goldin
- Division of Pediatric Surgery, Seattle Children׳s Hospital, Seattle, WA
| | - Keith T Oldham
- Division of Pediatric Surgery, Medical College of Wisconsin, Milwaukee, WI; Children׳s Hospital of Wisconsin, Milwaukee, WI
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Assessment of variation in care and outcomes for pediatric appendicitis at children's and non-children's hospitals. J Pediatr Surg 2015; 50:1885-92. [PMID: 26190133 DOI: 10.1016/j.jpedsurg.2015.06.012] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2015] [Revised: 05/21/2015] [Accepted: 06/07/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND Variation in care may indicate an opportunity for quality improvement and to decrease waste. Variation in appendicitis practice, resource use, and costs have not been well studied at non-children's hospitals (NCHs) where most children undergo care. The purpose of this study was to quantify variation in care for perforated pediatric appendicitis within and between children's hospitals (CHs) and NCH. METHODS Using the 2012 Kids' Inpatient Database, 11,216 children with perforated appendicitis were identified. Comparisons between CH and NCH were made in regard to operative approach (open versus laparoscopic), central line (CL) and total parenteral nutrition (PN) use, complication rates, length of stay (LOS), and total costs. RESULTS NCHs cared for 8051 patients (72%) with perforated appendicitis. CHs were more likely to perform a laparoscopy compared to NCHs (odds ratio (OR) 10.2, 95% confidence interval (95% CI) 5.7-18.2), and to utilize CL or PN than NCHs (CL OR 2.4 (95% CI 1.5-3.8), PN OR 2.6 (95% CI 1.4-4.9)). Composite complication rates were lower at CH (OR 0.5 (95% CI 0.4-0.6)). While LOS was not different between CH and NCH in the fully adjusted model, costs were higher at CH (OR 6.8 (95% CI 3.9-12.2)). Low and high outliers could be identified for each variable and outcome of interest with no consistent performance regardless of CH or NCH status. CONCLUSIONS Variation in operative approach, resource use, complications, LOS, and costs exist in the management of pediatric perforated appendicitis with greatest variation observed at NCH. Future quality improvement efforts should be tailored for implementation at both CH and high-volume NCH.
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Influence of hospital and patient location on early postoperative outcomes after appendectomy and pyloromyotomy. J Pediatr Surg 2015; 50:1549-55. [PMID: 25962842 DOI: 10.1016/j.jpedsurg.2015.03.063] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2014] [Revised: 03/15/2015] [Accepted: 03/22/2015] [Indexed: 02/08/2023]
Abstract
BACKGROUND The effects of hospital location and designation on postoperative pediatric outcomes remain unclear. We hypothesized that urban hospital outcomes would be superior to rural hospitals, and that outcomes at urban centers would differ for children from rural versus urban counties. METHODS Retrospective cohort study of children undergoing appendectomy (n=129,507) and pyloromyotomy (n=13,452) using the 2006/2009 KID databases. Hospitals were characterized by specialty designation and classified as urban/rural. County of residence was classified as urban/rural. Outcomes included complications and length of stay. Multivariate regression models were used to adjust for confounding. RESULTS Among appendectomy patients, treatment at urban hospitals was associated with reduced odds of any postoperative complication (OR=0.77, 95% C.I. 0.70-0.85) and anesthesia-related complications (OR=0.72, 95% C.I. 0.57-0.91). This association was strongest in the youngest children (<5 years) and at children's hospitals. For pyloromyotomy patients, urban hospitals were associated with reduced odds of any complication (OR=0.43, 95% C.I. 0.24-0.75), anesthesia-related complications (OR=0.14, 95% C.I. 0.05-0.37), and duodenal perforation (OR=0.46, 95% C.I. 0.19-1.07). These associations were most significant at children's hospitals. CONCLUSIONS Postoperative outcomes appear to be improved at urban specialty hospitals relative to rural hospitals for certain common pediatric procedures. Identification of the factors driving this association may help inform resource optimization efforts in pediatric surgery.
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Judhan RJ, Silhy R, Statler K, Khan M, Dyer B, Thompson S, Richmond B. The Integration of Adult Acute Care Surgeons into Pediatric Surgical Care Models Supplements the Workforce without Compromising Quality of Care. Am Surg 2015. [DOI: 10.1177/000313481508100916] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Acute care of children remains a challenge due to a shortage of pediatric surgeons, particularly in rural areas. In our institutional norm, all cases in patients age six and older are managed by dedicated general surgeons. The provision of care to these children by these surgeons alleviates the impact of such shortages. We conducted a five-year retrospective analysis of all acute care pediatric surgical cases performed in patients aged 6 to 17 years by a dedicated group of adult general surgeons in a rural tertiary care hospital. Demographics, procedure, complications, outcomes, length of stay, and time of consultation/operation were obtained via chart review. Elective, trauma related, or procedures performed by a pediatric surgeon were excluded. Descriptive statistics are reported. A total of 397 cases were performed by six dedicated general surgeons during the study period. Mean age was 11.5 ± 3.1 years. In all, 100 (25.2%) were transferred from outlying facilities and 52.6 per cent of consultations/operations occurred at night (7P–7A), of which 33.2 per cent occurred during late night hours (11P–7A). On weekends, 34.0 per cent occurred. Appendectomy was the most commonly performed operation (n = 357,89.9%), of which 311 were laparoscopic (87.1%). Others included incision/drainage (4.5%), laparoscopic cholecystectomy (2.0%), bowel resection (1.5%), incarcerated hernia (0.5%), small bowel obstruction (0.5%), intraabdominal abscess drainage (0.3%), resection of intussusception (0.3%), Graham patch (0.3%), and resection omental torsion (0.3%). Median length of stay was two days. Complications occurred in 23 patients (5.8%), of which 22(5.5%) were the result of the disease process. These results parallel those published by pediatric surgeons in this age group and for the diagnoses treated. Models integrating dedicated general surgeons into pediatric call rotations can be designed such that quality of pediatric care is maintained while providing relief to an overburdened pediatric surgical workforce.
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Affiliation(s)
- Rudy J. Judhan
- Department of Surgery, West Virginia University/Charleston Division, Charleston, West Virginia
| | - Raquel Silhy
- Department of Surgery, West Virginia University/Charleston Division, Charleston, West Virginia
| | - Kristen Statler
- Department of Surgery, West Virginia University/Charleston Division, Charleston, West Virginia
| | - Mija Khan
- West Virginia University School of Medicine, Charleston, West Virginia; and
| | - Benjamin Dyer
- Department of Surgery, West Virginia University/Charleston Division, Charleston, West Virginia
| | - Stephanie Thompson
- Charleston Area Medical Center Health Education and Research Institute, Charleston, West Virginia
| | - Bryan Richmond
- Department of Surgery, West Virginia University/Charleston Division, Charleston, West Virginia
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Abstract
Published outcome studies support regionalization of pediatric surgery, in which all children suspected of having surgical disease are transferred to a specialty center. Transfer to specialty centers, however, is an expensive approach to quality, both in direct costs of hospitalization and the expense incurred by families. A related question is the role of well-trained rural surgeons in an adequately resourced facility in the surgical care of infants and children. Local community facilities provide measurably equivalent results for straightforward emergencies in older children such as appendicitis. With education, training, and support such as telemedicine consultation, rural surgeons and hospitals may be able to care for many more children such as single-system trauma and other cases for which they have training such as pyloric stenosis. They can recognize surgical disease at earlier stages and initiate appropriate treatment before transfer so that patients are in better shape for surgery when they arrive for definitive care. Rural and community facilities would be linked in a pediatric surgery system that covers the spectrum of pediatric surgical conditions for a geographical region.
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Affiliation(s)
- Don K. Nakayama
- Department of Surgery, West Virginia University School of Medicine, Morgantown, West Virginia
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Abstract
We will discuss a new initiative of the American College of Surgeons and the American Pediatric Surgical Association to prospectively define optimal resource standards for children's surgical care.
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Affiliation(s)
- Keith T Oldham
- Division of Pediatric Surgery, Medical College of Wisconsin, Children's Hospital of Wisconsin, PO Box 1997, 9000W. Wisconsin Avenue, Milwaukee, WI 53201.
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