Effect of hospital type on the treatment of acute appendicitis in teenagers

Rates of Complications After Appendectomy in Children and Adolescents: Pediatric Surgical Compared to General Surgical Hospitals

BACKGROUND

Appendectomies in children and adolescents are performed in Germany in pediatric surgical (PS) or general surgical hospitals (GS). The aim of this study is to evaluate whether the surgery in a PS or GS hospital has an influence on the postoperative course after appendectomy in children and adolescents.

MATERIALS AND METHODS

Nationwide routine data from children and adolescents aged 1-17 y insured by the Local Health Insurance Fund who underwent appendectomy between 2014 and 2016 were analyzed (cohort study). Descriptive statistics were calculated both overall and in the two groups (PS and GS). Patients were additionally examined by age (1-5, 6-12, and 13-17 y), treatment (laparoscopic, open surgical, and conversion), and appendicitis type (nonacute: K36/K37/K38/R10, acute simple: K35.30/K35.8, and acute complex: K35.2/K35.31/K35.32). The influence of surgeon specialization on 90-d secondary surgery and 90-d general complications was assessed by multiple logistic regression.

RESULTS

Altogether, 25,065 patients who underwent surgery in 83 PS and 906 GS hospitals were included. Logistic regression analysis revealed that PS was associated with a reduced risk of interventions in the 1-5- and 6-12-y age groups (odds ratio: 0.44, 0.62). Acute complex appendicitis, comorbidities, and open surgery significantly increased the risk for reintervention. PS was associated with an increased risk for complications in the 13-17-y age group (odds ratio: 1.66).

CONCLUSIONS

PS and GS hospitals provided safe appendectomies in children and adolescents with low reintervention and complication rates. PS hospitals demonstrated advantages for patients in the 1-5- and 6-12-y age groups and GS hospitals for patients 13-17 y.

Exploring geographic variation in acute appendectomy in Ireland: results from a national registry study

OBJECTIVE

To explore geographic variations in Irish laparoscopic and open appendectomy procedures.

DESIGN

Analysis based on 2014-2017 administrative hospital data from public hospitals.

SETTING

Counties of Ireland.

PARTICIPANTS

Irish residents with hospital admissions for an appendectomy as the principal procedure.

MAIN OUTCOME MEASURES

Age and gender standardised laparoscopic and open appendectomy rates for 26 counties. Geographic variation measured with the extremal quotient (EQ), coefficient of variation (CV) and the systematic component of variation (SCV).

RESULTS

23 684 appendectomies were included. 77.6% (n= 18,387) were performed laparoscopically. An EQ of 8.3 for laparoscopy and 10.0 for open appendectomy was determined. A high CV was demonstrated with a value of 36.7 and 80.8 for laparoscopic and open appendectomy, respectively. An SCV of 14.2 and 124.8 for laparoscopic and open appendectomy was observed. A wider variation was determined when children and adults were assessed separately.

CONCLUSIONS

The geographic distribution in rates of appendectomy varies considerably across Irish counties. Our data suggest that a patient's likelihood of undergoing a laparoscopic or open appendectomy is associated with their county of residence.

Outcomes of Hospital Transfers for Pediatric Abdominal Pain and Appendicitis

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.