1
|
Jafari K, Gupta A, Caglar D, Hartford E. Potentially Avoidable Emergency Department Transfers for Acute Pediatric Respiratory Illness. Acad Pediatr 2024:S1876-2859(24)00289-4. [PMID: 39096998 DOI: 10.1016/j.acap.2024.07.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Revised: 07/23/2024] [Accepted: 07/26/2024] [Indexed: 08/05/2024]
Abstract
BACKGROUND Acute pediatric respiratory illness is one of the most common reasons for emergency department(ED) transfer however few studies have examined predictors of potentially avoidable ED transfer(PAT) in this subpopulation. This study aimed to characterize patterns and predictors of PATs in children with acute respiratory illness. METHODS Cross-sectional analysis of 8,402,577 visits for patients <17 years from 2018-2019 Health Care Utilization Project State ED and Inpatient Datasets from New York, Maryland, Wisconsin and Florida. ED transfers matched to a visit at a receiving facility with a primary diagnosis of pneumonia, croup/other URI, bronchiolitis or asthma were included. PAT was defined as discharge from receiving ED or within 24 hours of inpatient admission without specialized procedures, as previously described. PATs were compared with necessary transfers using a three-level generalized linear mixed model with adjustment for patient and hospital covariates. RESULTS Among 4,409 matched respiratory transfers, 25.5% were potentially avoidable. Most PATs originated from EDs within the third highest quartile of annual pediatric ED visits(n=472, 42.0%). In the multivariable model, likelihood of PAT was higher for patients with croup/other URI (OR 2.72 (2.09 -3.5) and if referring ED was in the highest quartile of annual pediatric ED volumes(OR 0.48 95% CI 0.26-0.88). CONCLUSIONS Pediatric respiratory transfers with a diagnosis of croup/other URI were the most likely to be potentially avoidable. Future implementation efforts to reduce PATs should consider focusing on croup management in EDs in the lower three quartiles of pediatric volume.
Collapse
Affiliation(s)
- Kaileen Jafari
- Department of Pediatric, Division of Emergency Medicine, University of Washington, Seattle, WA; Center for Clinical and Translation Research, Seattle Children's Hospital, Seattle, WA.
| | - Apeksha Gupta
- Center for Clinical and Translation Research, Seattle Children's Hospital, Seattle, WA; Children's Core for Biomedical Statistics, Seattle Children's Research Institute, Seattle, WA, USA
| | - Derya Caglar
- Department of Pediatric, Division of Emergency Medicine, University of Washington, Seattle, WA; Center for Clinical and Translation Research, Seattle Children's Hospital, Seattle, WA
| | - Emily Hartford
- Department of Pediatric, Division of Emergency Medicine, University of Washington, Seattle, WA; Center for Clinical and Translation Research, Seattle Children's Hospital, Seattle, WA
| |
Collapse
|
2
|
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.
Collapse
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
| |
Collapse
|
3
|
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.
Collapse
|
4
|
Baschat AA, Blackwell SB, Chatterjee D, Cummings JJ, Emery SP, Hirose S, Hollier LM, Johnson A, Kilpatrick SJ, Luks FI, Menard MK, McCullough LB, Moldenhauer JS, Moon-Grady AJ, Mychaliska GB, Narvey M, Norton ME, Rollins MD, Skarsgard ED, Tsao K, Warner BB, Wilpers A, Ryan G. Care Levels for Fetal Therapy Centers. Obstet Gynecol 2022; 139:1027-1042. [PMID: 35675600 PMCID: PMC9202072 DOI: 10.1097/aog.0000000000004793] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 02/03/2022] [Indexed: 01/05/2023]
Abstract
Fetal therapies undertaken to improve fetal outcome or to optimize transition to neonate life often entail some level of maternal, fetal, or neonatal risk. A fetal therapy center needs access to resources to carry out such therapies and to manage maternal, fetal, and neonatal complications that might arise, either related to the therapy per se or as part of the underlying fetal or maternal condition. Accordingly, a fetal therapy center requires a dedicated operational infrastructure and necessary resources to allow for appropriate oversight and monitoring of clinical performance and to facilitate multidisciplinary collaboration between the relevant specialties. Three care levels for fetal therapy centers are proposed to match the anticipated care complexity, with appropriate resources to achieve an optimal outcome at an institutional and regional level. A level I fetal therapy center should be capable of offering fetal interventions that may be associated with obstetric risks of preterm birth or membrane rupture but that would be very unlikely to require maternal medical subspecialty or intensive care, with neonatal risks not exceeding those of moderate prematurity. A level II center should have the incremental capacity to provide maternal intensive care and to manage extreme neonatal prematurity. A level III therapy center should offer the full range of fetal interventions (including open fetal surgery) and be able manage any of the associated maternal complications and comorbidities, as well as have access to neonatal and pediatric surgical intervention including indicated surgery for neonates with congenital anomalies.
Collapse
Affiliation(s)
- Ahmet A. Baschat
- Johns Hopkins Center for Fetal Therapy, Department of Gynecology &Obstetrics, Johns Hopkins University
| | - Sean B Blackwell
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Texas, Mc Govern Medical School
| | - Debnath Chatterjee
- Department of Anesthesiology, Children’s Hospital Colorado/Colorado Fetal Care Center, University of Colorado School of Medicine
| | | | - Stephen P. Emery
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology & Reproductive Sciences, University of Pittsburgh School of Medicine
| | - Shinjiro Hirose
- Division of Pediatric, General, Thoracic and Fetal Surgery, Department of Surgery, University of California Davis Medical Center
| | - Lisa M. Hollier
- Division of Maternal-Fetal; Medicine, Department of Obstetrics & Gynecology, Baylor College of Medicine
| | - Anthony Johnson
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Texas, Mc Govern Medical School
| | | | - Francois I Luks
- Department of Surgery, Alpert Medical School of Brown University and Hasbro Children’s Hospital
| | - M. Kathryn Menard
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, University of North Carolina School of Medicine, Chapel Hill
| | | | - Julie S. Moldenhauer
- Center for Fetal Diagnosis and Treatment, Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania
| | - Anita J. Moon-Grady
- Division of Pediatric Cardiology, Department of Clinical Pediatrics, University of California, San Francisco
| | - George B. Mychaliska
- Department of Pediatric Surgery, C.S. Mott Children’s Hospital, University of Michigan
| | - Michael Narvey
- Division of Neonatology, Department of Pediatrics, University of Manitoba
| | - Mary E. Norton
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco
| | | | - Eric D. Skarsgard
- Centre for Surgical Research, Department of Surgery, BC Children’s Hospital, University of British Columbia
| | - KuoJen Tsao
- Division of Pediatric General and Thoracic Surgery, Department of Surgery, University of Texas, Mc Govern Medical School
| | - Barbara B. Warner
- Division of Newborn Medicine, Department of Pediatrics, Washington University School of Medicine
| | | | - Greg Ryan
- Ontario Fetal Care Centre, Mount Sinai Hospital, University of Toronto
| |
Collapse
|
5
|
Abstract
IMPORTANCE Although children's hospitals (CH) provide a substantial proportion of highly specialized pediatric care in the United States, the value of CH compared with non-children's hospitals (NCH) for routine surgical procedures is unknown. OBJECTIVE To examine the value of CH for routine surgical procedures by assessing clinical outcomes and payment data. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study examined pediatric patients undergoing 1 of 13 commonly performed surgical procedures between 2010 and 2015 with 90-day follow-up using administrative data from the Health Care Cost Institute. Data analysis was conducted from July 2019 to December 2021. EXPOSURES The primary exposure was tier of CH status, defined using self-reported pediatric services, affiliation with pediatric focused programs, and validated based on proportion of pediatric admissions. MAIN OUTCOMES AND MEASURES Payments for common surgical procedures from private insurers and overall complication and readmission rates at 30, 60, and 90 days. RESULTS There were 368 220 pediatric patients who underwent one of the surgical procedures of interest; 220 899 (60.0%) of the patients were male; 118 977 (32.3%) had their procedure at freestanding CH (CH-A), 75 256 (20.4%) at CH attached to an adult hospital (CH-B), and 173 987 (47.3%) at NCH. The mean (SD) payment for all procedures at CH-A was $6533.56 ($6399.97), $5847.50 ($4947.47) at CH-B, and $5034.25 ($4787.07) at NCH. The mean (SD) overall complication rate was 0.004 (0.06) at CH-A, 0.01 (0.07) at CH-B, and 0.003 (0.06) at NCH. Readmission rates at 30, 60, and 90 days were similar across all hospital types. After adjusting for zip code, year, surgery, surgery setting, and observable patient, hospital, and county characteristics, the estimated payments for inpatient common procedures were 39% higher at CH-A than at NCH. Payments for outpatient common procedures were 34% higher at CH-A than at NCH. CONCLUSIONS AND RELEVANCE In this cohort study, children who underwent common surgical procedures had equivalent clinical outcomes at CH and NCH but the procedures were associated with higher payments and, thus, overall lower value care. To ensure delivery of optimal value to patients and payers, more research is needed to evaluate mechanisms to ensure access, decrease costs, and improve value at both CH and NCH.
Collapse
Affiliation(s)
- Mehul V. Raval
- Department of Surgery and Pediatrics, Surgical Outcomes and Quality Improvement Center, Center for Healthcare Studies, Institute of Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Division of Pediatric Surgery, Department of Surgery, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Audra J. Reiter
- Department of Surgery and Pediatrics, Surgical Outcomes and Quality Improvement Center, Center for Healthcare Studies, Institute of Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Division of Pediatric Surgery, Department of Surgery, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | | |
Collapse
|
6
|
Williamson CG, Ng A, Richardson S, Li E, Benharash P, DeUgarte DA, Wagner JP. Hospital Variation in Surgical Technique for Repair of Uncomplicated Gastroschisis. Am Surg 2022; 88:2480-2485. [PMID: 35549512 DOI: 10.1177/00031348221101511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Practices in surgical repair of uncomplicated gastroschisis are varied. Data regarding hospital volume, surgical technique, clinical outcomes, and costs remain limited. Neonatal patients with uncomplicated gastroschisis were identified using the 2015-2019 National Readmissions Database. Hospital volume tertiles were determined, and sutureless or fascial repair techniques were enumerated. High volume centers (HVC) comprised the top tertile. Hospital-level variability in surgical technique was determined. Adjusted multivariable analysis was performed to compare clinical outcomes and costs among HVC and lower-volume centers and among repair techniques. Of an estimated 2903 hospitalizations meeting inclusion criteria, 23.5% occurred at HVC. There was 42.4% variation among sutureless and fascial repair techniques across all hospitals. Among HVC and lower-volume centers, there were no significant differences in rates of 30-day readmission or complication; however, HVC were associated with greater cost and length of stay. Those with codes for fascial repair technique experienced greater lengths of stay, costs, and rates of complication. Codes for surgical repair technique for uncomplicated gastroschisis vary widely, while outcomes are equivalent across strata of hospital volume. Those with codes for sutureless technique were associated with favorable clinical outcomes, irrespective of hospital volume. Guidelines for management of uncomplicated gastroschisis should account for hospital volume, variation in technique, outcomes, and resource utilization.
Collapse
Affiliation(s)
- Catherine G Williamson
- Department of Surgery, 8783David Geffen School of Medicine of UCLA, Los Angeles, CA, USA
| | - Ayesha Ng
- Department of Surgery, 8783David Geffen School of Medicine of UCLA, Los Angeles, CA, USA
| | - Shannon Richardson
- Department of Surgery, 8783David Geffen School of Medicine of UCLA, Los Angeles, CA, USA
| | - Erica Li
- Division of Pediatric Critical Care, 8783David Geffen School of Medicine of UCLA, Los Angeles, CA, USA
| | - Peyman Benharash
- Department of Surgery, 8783David Geffen School of Medicine of UCLA, Los Angeles, CA, USA.,Division of Cardiac Surgery, 8783David Geffen School of Medicine of UCLA, Los Angeles, CA, USA
| | - Daniel A DeUgarte
- Department of Surgery, 8783David Geffen School of Medicine of UCLA, Los Angeles, CA, USA.,Division of Pediatric Surgery, 8783David Geffen School of Medicine of UCLA, Los Angeles, CA, USA
| | - Justin P Wagner
- Department of Surgery, 8783David Geffen School of Medicine of UCLA, Los Angeles, CA, USA.,Division of Pediatric Surgery, 8783David Geffen School of Medicine of UCLA, Los Angeles, CA, USA
| |
Collapse
|
7
|
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]
|
8
|
McEvoy CS, Ross-Li D, Held JM, Jones DA, Rice-Townsend S, Weldon CB, Ricca RL. Geographic distance to pediatric surgical care within the continental United States. J Pediatr Surg 2019; 54:1112-1117. [PMID: 30922686 DOI: 10.1016/j.jpedsurg.2019.02.048] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 02/21/2019] [Indexed: 10/27/2022]
Abstract
PURPOSE Geographic proximity to pediatric surgical care has not been evaluated using the Decennial Census nor have racial, ethnic, gender, or urbanization variations been reported. This study's aim is to describe proximity of children living in the continental U.S. to a pediatric surgeon with respect to these variations. METHODS The 2010 American Pediatric Surgical Association member file and the 2010 Decennial Census were used to calculate straight-line distances between pediatric surgeons' zip code centroids and census block centroids. RESULTS In 2010, 716 practicing pediatric surgeons were identified, 6,182,882 populated Census blocks were identified, and 73,690,271 children were enumerated. Of white non-Hispanic children, 30.1% lived greater than 40 miles from care. Of Native American children, 40.5% lived more than 60 miles from care. Among children 0-5 years of age, the median (IQR) miles to closest pediatric surgeon was 14.2 (6.2, 39.6), and 3,010,698 of these children lived more than 60 miles from care. CONCLUSION More than 10 million children lived greater than 60 miles from a pediatric surgeon in 2010. Racial, ethnic, age, and urbanization variations in proximity to pediatric surgeons were present. This method is feasible to describe distance-to-care with the upcoming 2020 Decennial Census and may benefit future allocation of pediatric surgeons. LEVEL OF EVIDENCE IV.
Collapse
Affiliation(s)
- Christian S McEvoy
- Department of Surgery, Naval Medical Center Portsmouth, Portsmouth, VA; Department of Heath Analysis, Navy and Marine Corps Public Health Center, Portsmouth, VA.
| | - Dan Ross-Li
- University of Chicago Booth School of Business, Chicago, IL
| | - Jenny M Held
- Department of Surgery, Naval Medical Center Portsmouth, Portsmouth, VA
| | - Darcy A Jones
- Department of Surgery, Naval Medical Center Portsmouth, Portsmouth, VA
| | - Samuel Rice-Townsend
- Departments of Surgery, Critical Care & Pain Medicine, Boston Children's Hospital, Boston, MA
| | - Christopher B Weldon
- Departments of Surgery, Critical Care & Pain Medicine, Boston Children's Hospital, Boston, MA
| | - Robert L Ricca
- Department of Surgery, Naval Medical Center Portsmouth, Portsmouth, VA; Department of Pediatric Surgery, Naval Medical Center Portsmouth, Portsmouth, VA
| |
Collapse
|
9
|
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.
Collapse
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
| |
Collapse
|
10
|
Pediatric appendicitis: Is referral to a regional pediatric center necessary? J Trauma Acute Care Surg 2019; 84:636-641. [PMID: 29283967 DOI: 10.1097/ta.0000000000001787] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Acute appendicitis is the most common emergent surgical procedure performed among children in the United States, with an incidence exceeding 80,000 cases per year. Appendectomies are often performed by both pediatric surgeons and adult general/trauma and acute care (TACS) surgeons. We hypothesized that children undergoing appendectomy for acute appendicitis have equivalent outcomes whether a pediatric surgeon or a TACS surgeon performs the operation. METHODS A retrospective chart review was performed for patients 6 to 18 years of age, who underwent appendectomy at either a regional children's hospital (Children's Hospital of Colorado [CHCO], n = 241) or an urban safety-net hospital (n = 347) between July 2010 and June 2015. The population of patients operated on at the urban safety-net hospital was further subdivided into those operated on by pediatric surgeons (Denver Health Medical Center [DHMC] pediatric surgeons, n = 68) and those operated on by adult TACS surgeons (DHMC TACS, n = 279). Baseline characteristics and operative outcomes were compared between these patient populations utilizing one-way analysis of variance and χ test for independence. RESULTS When comparing the CHCO and DHMC TACS groups, there were no differences in the proportion of patients with perforated appendicitis, operative time, rate of operative complications, rate of postoperative infectious complications, or rate of 30-day readmission. Length of stay was significantly shorter for the DHMC TACS group than that for the CHCO group. CONCLUSIONS Our data demonstrate that among children older than 5 years undergoing appendectomy, length of stay, risk of infectious complications, and risk of readmission do not differ regardless of whether they are operated on by pediatric surgeons or adult TACS surgeons, suggesting resources currently consumed by transferring children to hospitals with access to pediatric surgeons could be allocated elsewhere. LEVEL OF EVIDENCE Therapeutic/Care management, level III.
Collapse
|
11
|
Muffly MK, Singleton M, Agarwal R, Scheinker D, Miller D, Muffly TM, Honkanen A. The Pediatric Anesthesiology Workforce: Projecting Supply and Trends 2015-2035. Anesth Analg 2018; 126:568-578. [PMID: 29116973 DOI: 10.1213/ane.0000000000002535] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND A workforce analysis was conducted to predict whether the projected future supply of pediatric anesthesiologists is balanced with the requirements of the inpatient pediatric population. The specific aims of our analysis were to (1) project the number of pediatric anesthesiologists in the future workforce; (2) project pediatric anesthesiologist-to-pediatric population ratios (0-17 years); (3) project the mean number of inpatient pediatric procedures per pediatric anesthesiologist; and (4) evaluate the effect of alternative projections of individual variables on the model projections through 2035. METHODS The future number of pediatric anesthesiologists is determined by the current supply, additions to the workforce, and departures from the workforce. We previously compiled a database of US pediatric anesthesiologists in the base year of 2015. The historical linear growth rate for pediatric anesthesiology fellowship positions was determined using the Accreditation Council for Graduate Medical Education Data Resource Books from 2002 to 2016. The future number of pediatric anesthesiologists in the workforce was projected given growth of pediatric anesthesiology fellowship positions at the historical linear growth rate, modeling that 75% of graduating fellows remain in the pediatric anesthesiology workforce, and anesthesiologists retire at the current mean retirement age of 64 years old. The baseline model projections were accompanied by age- and gender-adjusted anesthesiologist supply, and sensitivity analyses of potential variations in fellowship position growth, retirement, pediatric population, inpatient surgery, and market share to evaluate the effect of each model variable on the baseline model. The projected ratio of pediatric anesthesiologists to pediatric population was determined using the 2012 US Census pediatric population projections. The projected number of inpatient pediatric procedures per pediatric anesthesiologist was determined using the Kids' Inpatient Database historical data to project the future number of inpatient procedures (including out of operating room procedures). RESULTS In 2015, there were 5.4 pediatric anesthesiologists per 100,000 pediatric population and a mean (±standard deviation [SD]) of 262 ±8 inpatient procedures per pediatric anesthesiologist. If historical trends continue, there will be an estimated 7.4 pediatric anesthesiologists per 100,000 pediatric population and a mean (±SD) 193 ±6 inpatient procedures per pediatric anesthesiologist in 2035. If pediatric anesthesiology fellowship positions plateau at 2015 levels, there will be an estimated 5.7 pediatric anesthesiologists per 100,000 pediatric population and a mean (±SD) 248 ±7 inpatient procedures per pediatric anesthesiologist in 2035. CONCLUSIONS If historical trends continue, the growth in pediatric anesthesiologist supply may exceed the growth in both the pediatric population and inpatient procedures in the 20-year period from 2015 to 2035.
Collapse
Affiliation(s)
- Matthew K Muffly
- From the Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University Medical Center, Stanford, California
| | - Mark Singleton
- From the Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University Medical Center, Stanford, California
| | - Rita Agarwal
- From the Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University Medical Center, Stanford, California
| | - David Scheinker
- Department of Management Science and Engineering at Stanford University, Stanford University, Stanford, California
| | - Daniel Miller
- Department of Management Science and Engineering at Stanford University, Stanford University, Stanford, California
| | - Tyler M Muffly
- Department of Obstetrics and Gynecology, Denver Health Medical Center, Denver, Colorado
| | - Anita Honkanen
- From the Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University Medical Center, Stanford, California
| |
Collapse
|
12
|
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]
|
13
|
The American College of Surgeons Children's Surgery Verification and Quality Improvement Program: Be Careful What You Wish For! Anesth Analg 2018; 126:1438-1440. [PMID: 29672380 DOI: 10.1213/ane.0000000000002810] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
14
|
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]
|
15
|
Pediatric Cardiopulmonary Arrest in the Postanesthesia Care Unit, Rare but Preventable. Anesth Analg 2017; 124:1231-1236. [DOI: 10.1213/ane.0000000000001744] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
16
|
Increased pediatric sub-specialization is associated with decreased surgical complication rates for inpatient pediatric urology procedures. J Pediatr Urol 2016; 12:388.e1-388.e7. [PMID: 27363329 PMCID: PMC5161733 DOI: 10.1016/j.jpurol.2016.05.034] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Accepted: 05/16/2016] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Increased case volumes and training are associated with better surgical outcomes. However, the impact of pediatric urology sub-specialization on perioperative complication rates is unknown. OBJECTIVES To determine the presence and magnitude of difference in rates of common postoperative complications for elective pediatric urology procedures between specialization levels of urologic surgeons. The Nationwide Inpatient Sample (NIS), a nationally representative administrative database, was used. STUDY DESIGN The NIS (1998-2009) was retrospectively reviewed for pediatric (≤18 years) admissions, using ICD-9-CM codes to identify urologic surgeries and National Surgical Quality Improvement Program (NSQIP) inpatient postoperative complications. Degree of pediatric sub-specialization was calculated using a Pediatric Proportion Index (PPI), defined as the ratio of children to total patients operated on by each provider. The providers were grouped into PPI quartiles: Q1, 0-25% specialization; Q2, 25-50%; Q3, 50-75%; Q4, 75-100%. Weighted multivariate analysis was performed to test for associations between PPI and surgical complications. RESULTS A total of 71,479 weighted inpatient admissions were identified. Patient age decreased with increasing specialization: Q1, 7.9 vs Q2, 4.8 vs Q3, 4.8 vs Q4, 4.6 years, P < 0.01). Specialization was not associated with race (P > 0.20), gender (P > 0.50), or comorbidity scores (P = 0.10). Mortality (1.5% vs 0.2% vs 0.3% vs 0.4%, P < 0.01) and complication rates (15.5% vs 11.7% vs 9.6% vs 10.9%, P < 0.0001) both decreased with increasing specialization. Patients treated by more highly specialized surgeons incurred slightly higher costs (Q2, +4%; Q3, +1%; Q4 + 2%) but experienced shorter length of hospital stay (Q2, -5%; Q3, -10%; Q4, -3%) compared with the least specialized providers. A greater proportion of patients treated by Q1 and Q3 specialized urologists had CCS ≥2 than those seen by Q2 or Q4 urologists (12.5% and 12.2%, respectively vs 8.4% and 10.9%, respectively, P = 0.04). Adjusting for confounding effects, increased pediatric specialization was associated with decreased postoperative complications: Q2 OR 0.78, CI 0.58-1.05; Q3 OR 0.60, CI 0.44-0.84; Q4 OR 0.70, CI 0.58-0.84; P < 0.01. DISCUSSION Providers with proportionally higher volumes of pediatric patients achieved better postoperative outcomes than their less sub-specialized counterparts. This may have arisen from increased exposure to pediatric anatomy and physiology, and greater familiarity with pediatric techniques. LIMITATION The NIS admission-based retrospective design did not enable assessment of long-term outcomes, repeated admissions, or to track a particular patient across time. The study was similarly limited in evaluating the effect of pre-surgical referral patterns on patient distributions. CONCLUSIONS Increased pediatric sub-specialization among urologists was associated with a decreased risk of mortality and surgical complications in children undergoing inpatient urologic procedures.
Collapse
|
17
|
|
18
|
Langer JC, Gordon JS, Chen LE. Subspecialization within pediatric surgical groups in North America. J Pediatr Surg 2016; 51:143-8. [PMID: 26541313 DOI: 10.1016/j.jpedsurg.2015.10.038] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Accepted: 10/09/2015] [Indexed: 11/15/2022]
Abstract
PURPOSE The purpose of this study was to assess the current status of subspecialization in North American pediatric surgical practices and to evaluate factors associated with subspecialization. METHODS A survey was sent to each pediatric surgical practice in the United States and Canada. For each of 44 operation types, ranging in complexity and volume, the respondents chose one of the following responses: 1. everyone does the operation; 2. group policy--only some surgeons do the operation; 3. group policy--anyone can do it but mentorship required; 4. only some do it due to referral patterns; 5. no one in the group does it. Association of various factors with degree of subspecialization was analyzed using nonparametric statistics with p<0.05 considered significant. RESULTS Response rate was 70%. There was significant variability in subspecialization among groups. Factors found to be significantly associated with increased subspecialization included free-standing children's hospitals, pediatric surgery training programs, higher number of surgeons, higher case volume, and greater volume of tertiary/quaternary cases. CONCLUSIONS There is wide variation in the degree of subspecialization among North American pediatric surgery practices. These data will help to inform ongoing debate around strategies that may be useful in optimizing pediatric surgical care and patient outcomes in the future.
Collapse
Affiliation(s)
- Jacob C Langer
- Division of General and Thoracic Surgery, Hospital for Sick Children, Toronto, ON, Canada; Department of Surgery, University of Toronto, Toronto, ON, Canada.
| | - Jennifer S Gordon
- Division of General and Thoracic Surgery, Hospital for Sick Children, Toronto, ON, Canada; Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Li Ern Chen
- Department of Surgery, Baylor University Medical Center, Dallas, TX, USA
| |
Collapse
|
19
|
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.
Collapse
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
| |
Collapse
|
20
|
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.
Collapse
|
21
|
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.
Collapse
|
22
|
Oldham KT, Fallat M, Barnhart D, Derkay C, Deshpande J, Georgeson K, Hirschl R, Houck C, Mooney D, Moss RL, Sawin R, Tuggle D. Reply to a Letter to the Editor. J Pediatr Surg 2015; 50:1434-6. [PMID: 26162971 DOI: 10.1016/j.jpedsurg.2015.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Accepted: 06/07/2015] [Indexed: 10/23/2022]
Affiliation(s)
| | - Keith T Oldham
- American College of Surgeons Committee for Children's Surgery.
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|