Regionalization of the surgical care of children: A risk-adjusted comparison of hospital surgical outcomes by geographic areas

Outcomes After Pectus Excavatum Repair: Center Volume Matters

PURPOSE

Pectus excavatum (Pectus) repair may be offered for those with significant cardiopulmonary compromise or severe cosmetic defects. The influence of hospital center volume on postoperative outcomes in children is unknown. This study aimed to investigate the outcomes of children undergoing Pectus repair, stratified by hospital surgical volume.

METHODS

The Nationwide Readmission Database was queried (2016-2020) for patients with Pectus (Q67.6). Patients were stratified into those who received repair at high-volume centers (HVCs; ≥20 repairs annually) versus low-volume centers (LVCs; <20 repairs annually). Demographics and outcomes were analyzed using standard statistical tests.

RESULTS

A total of 9414 patients with Pectus underwent repair during the study period, with 69% treated at HVCs and 31% at LVCs. Patients at LVCs experienced higher rates of complications during index admission, including pneumothorax (23% vs. 15%), chest tube placement (5% vs. 2%), and overall perioperative complications (28% vs. 24%) compared to those treated at HVCs, all p < 0.001. Patients treated at LVCs had higher readmission rates within 30 days (3.8% vs. 2.8% HVCs) and overall readmission (6.8% vs. 4.7% HVCs), both p < 0.010. Among readmitted patients (n = 547), the most frequent complications during readmission for those initially treated at LVCs included pneumothorax/hemothorax (21% vs. 8%), bar dislodgment (21% vs. 12%), and electrolyte disorders (15% vs. 9%) compared to those treated at HVCs.

CONCLUSION

Pediatric Pectus repair performed at high-volume centers was associated with fewer index complications and readmissions compared to lower-volume centers. Patients and surgeons should consider this hospital volume-outcome relationship.

TYPE OF STUDY

Retrospective Comparative.

LEVEL OF EVIDENCE

III.

Do Unpaid Children's Hospital Account Balances Correlate with Family Income or Insurance Type?

Background

Current understanding of medical debt among various income ranges and insurance carriers is limited. We analyzed median household incomes, insurance carriers, and medical debt of plastic surgery patients at a major metropolitan children's hospital.

Methods

A retrospective chart review for zip codes, insurance carriers, and account balances was conducted for 2018-2021. All patients were seen by members of the Division of Pediatric Plastic Surgery at Ann and Robert H. Lurie Children's Hospital of Chicago. Blue Cross was reported separately among other commercial insurance carriers by the hospital's business analytics department. Median household income by zip code was obtained. IBM SPSS Statistics was used to perform chi-squared tests to study the distribution of unpaid account balances by income ranges and insurance carriers.

Results

Of the 6877 patients, 630 had unpaid account balances. Significant differences in unpaid account balances existed among twelve insurance classes (P < 0.001). There were significant differences among unpaid account balances when further examined by median household income ranges for Blue Cross (P < 0.001) and other commercial insurance carriers (P < 0.001).

Conclusions

Although patients with insurance policies requiring higher out-of-pocket costs (ie, Blue Cross and other commercial insurance carriers) are generally characterized by higher household incomes, these patients were found to have higher unpaid account balances than patients with public insurance policies. This suggests that income alone is not predictive of unpaid medical debt and provides greater appreciation of lower income families who may make a more consistent effort in repaying their medical debt.

Association of Operative Volume and Odds of Surgical Complication for Patients Undergoing Repair of Pectus Excavatum at Children's Hospitals

OBJECTIVE

To determine whether procedure-specific provider volume is associated with outcomes for patients undergoing repair of pectus excavatum at tertiary care children's hospitals.

STUDY DESIGN

We performed a cohort study of patients undergoing repair of pectus excavatum between January 1, 2013 and December 31, 2019, at children's hospitals using the Pediatric Health Information System database. The main exposures were the pectus excavatum repair volume quartile of the patient's hospital and the pectus excavatum repair volume category of their surgeon. Our primary outcome was surgical complication, identified using International Classification of Diseases, Ninth Revision, Clinical Modification, and International Classification of Diseases, Tenth Revision, Clinical Modification codes from Pediatric Health Information System. Secondary outcomes included high-cost admission and extended length of stay.

RESULTS

In total, 7183 patients with an average age of 15.2 years (SD 2.0), 83% male, 74% non-Hispanic White, 68% no comorbidities, 72% private insurance, and 82% from metro areas were analyzed. Compared with the lowest-volume (≤10 cases/year) quartile of hospitals, patients undergoing repair of pectus excavatum at hospitals in the second (>10-18 cases/year), third (>18-26 cases/year), and fourth (>26 cases/year) volume quartiles had decreased odds of complication of OR 0.52 (CI 0.34-0.82), 0.51 (CI 0.33-0.78), and 0.41 (CI 0.27-0.62), respectively. Patients with pectus excavatum who underwent repair by surgeons in the second (>1-5 cases/year), third (>5-10 cases/year), and fourth (>10 cases/year) volume categories had decreased odds of complication of OR 0.91 (CI 0.68-1.20), OR 0.73 (CI 0.51-1.04), and OR 0.55 (CI 0.39-0.76), respectively, compared with the lowest-volume (≤1 case/year) category of surgeons.

CONCLUSIONS

Procedure-specific case volume is an important factor when considering providers for elective surgery, even among specialized centers providing comprehensive patient care.

Availability of Inpatient Pediatric Surgery in the United States

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

High acuity polytrauma centers in orthopaedic trauma: Decreasing patient mortality with effective resource utilization

BACKGROUND

There is a select number of massive-volume, high-acuity trauma centers (HACs) in the United States. Expertise in polytrauma care has been associated with improved mortality in general surgery trauma, though has not been investigated in orthopaedic trauma. With complex polytrauma proficiency comes the inherent risk of intensive care, complications, and prolonged inpatient stays, without a commensurate increase in allocated resources. The purpose of this study was to compare mortality, complications, and length of stay in polytraumatized orthopaedic patients treated at HACs vs. low-acuity trauma centers (LACs).

METHODS

The National Trauma Data Bank was queried for orthopaedic injuries with injury severity score (ISS)>15 and mortality, complications, hospital length of stay, ICU length of stay, ventilation duration, and demographics. Hospitals where at least 13% (median percentage of patients with ISS > 15 admitted to all hospitals) of total admissions had an ISS>15 were classified as HAC; all others were LACs.

RESULTS

HACs admitted 86.8% of 28,314 patients with ISS>15. On univariate analysis, patients at HACs have 16% decreased odds of in-hospital mortality vs. LACs (p=0.005); the effect increased to 27% (p=0.002) on multivariate analysis. Patients at HACs have 63% greater odds of ICU admission (p<0.001), 48% higher odds of ventilatory support (p=<0.001), 38% increased odds of unplanned reoperation (p=0.007), and 37% increased odds of medical complications (p<0.001). On multivariate analysis, secondary outcome measures showed no significant difference between HACs and LACs. Patients at HACs had 2.8 days longer length-of-stay (p<0.001).

CONCLUSION

Severely injured orthopaedic trauma patients have decreased mortality at HACs, despite having a higher average ISS and a higher prevalence of obesity and active smoking. While there is a higher incidence of ICU admission, mechanical ventilation, complications, and unplanned reoperation on univariate analysis, correction for ISS and patient factors enhances the effect of HACs on mortality, but removes the effect on secondary measures. Thus, HACs are life-saving institutions for polytraumatized orthopaedic patients, and the known resource demand of these hospitals is supported by their favorable outcome profile.

LEVEL OF EVIDENCE

IV.

Assessment of Epidemiological Trends in Craniosynostosis: Limitations of the Current Classification System

Craniosynostosis affects 1 in 2,000 live births, which makes it one of the most common craniofacial abnormalities in the United States. Despite this fact, few national epidemiologic reports exist, although US and European studies have reported an increased incidence of metopic craniosynostosis. The aim of our study is to analyze the National Inpatient Sample (NIS) to support those conclusions.

Trends in Routine and Complex Hepatobiliary Surgery Among General and Pediatric Surgical Residents: What is the Next Generation Learning and is it Enough?

OBJECTIVE

Previous studies reveal a correlation between surgical volume and outcomes; thus, a similar relationship likely exists between trainee operative volume and technical competence. While routine hepatobiliary surgery is commonplace, trainee exposure to the more advanced procedures may be lacking. We hypothesize that experience in complex hepatobiliary procedures may be deficient both during general surgery residency and pediatric surgery fellowship training.

DESIGN

Case log data from the ACGME were queried for general surgery residents (2000-2017) and pediatric surgery fellows (2004-2017). Laparoscopic cholecystectomy was considered a routine hepatobiliary procedure for both specialties. For general surgery, hepatic lobectomy/segmentectomy and choledochoenteric anastomosis were considered complex and for pediatric surgery, hepatic lobectomy, biliary atresia and choledochal cyst procedures were considered complex.

SETTING

Publicly available case log data from the ACGME.

PARTICIPANTS

General surgery residents and pediatric surgery fellows at ACGME-accredited training programs.

RESULTS

The number of trainees increased over the study period for both groups. Mean case volumes for laparoscopic cholecystectomy increased by 36% in surgery graduates and by 114% in pediatric surgery graduates. In surgery, the mean volumes for choledochoenteric anastomosis procedures decreased by 53% from 3.0 to 1.4 procedures/year with increasing variability in trainee experience. Volumes for hepatic lobectomy/segmentectomy increased by 68% from 3.4 to 5.7 procedures/year with decreasing variability. In pediatric surgery, case volumes for complex procedures were low (mean <4/year), highly variable among trainees, and appear unchanged between 2004 and 2017. In every year analyzed, at least 1 pediatric surgery trainee reported doing 0 cases in one of these complex categories.

CONCLUSIONS

Case logs suggest that the volume of complex hepatobiliary surgery remains low and highly variable in both disciplines with some trainees obtaining minimal or no exposure to certain cases. The relationship between these trends and the development of competency is worthy of further study.

Pediatric Oncology Discharges With Febrile Neutropenia: Variation in Location of Care

We examined the use of Pediatric Cancer Specialty Centers (PCSCs) over time and the length of stay (LOS) in pediatric oncology patients with a diagnosis of febrile neutropenia. PCSCs were defined as Children's Oncology Group and California Children's Services designated centers. We performed a retrospective analysis on all discharges of pediatric (0 to 18) oncology patients with febrile neutropenia in California (1983 to 2011) using the private Office of Statewide Health Planning and Development database. We examined influence of age, sex, race/ethnicity, payer, income, distance, tumor type, and complications on utilization of PCSCs and LOS (SAS 9.2). Analysis of 24,559 pediatric oncology febrile neutropenia discharges showed hospitalizations in PCSCs increasing from 48% in 1983 to 94% in 2011. The adjusted regression analysis showed decreased PCSC utilization for ages 15 to 18, Hispanic patients, and those living >40 miles away. The median PCSC LOS was 9 days compared with 7 days at a non-PCSC (P<0.0001). Discharge from a PCSC was associated with a LOS >8 days after controlling for complications. Inpatient PCSC care for febrile neutropenia in California has increased since 1983. Receiving care at a PCSC is influenced by age, tumor type, ethnicity, geography, and complications.

Impact of hospital transfer on surgical outcomes of intestinal atresia

BACKGROUND

Examine effects of hospital transfer into a quaternary care center on surgical outcomes of intestinal atresia.

METHODS

Children <1 yo principally diagnosed with intestinal atresia were identified using the Kids' Inpatient Database (2012). Exposure variable was patient transfer status. Outcomes measured were inpatient mortality, hospital length of stay (LOS) and discharge status. Linearized standard errors, design-based F tests, and multivariable logistic regression were performed.

RESULTS

1672 weighted discharges represented a national cohort. The highest income group and those with private insurance had significantly lower odds of transfer (OR:0.53 and 0.74, p < 0.05). Rural patients had significantly higher transfer rates (OR: 2.73, p < 0.05). Multivariate analysis revealed no difference in mortality (OR:0.71, p = 0.464) or non-home discharge (OR: 0.79, p = 0.166), but showed prolonged LOS (OR:1.79, p < 0.05) amongst transferred patients.

CONCLUSIONS

Significant differences in hospital LOS and treatment access reveal a potential healthcare gap. Post-acute care resources should be improved for transferred patients.

Optimization of care for the pediatric surgical patient: Why now?

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.

Pain and Health-Related Quality of Life After Pediatric Inpatient Surgery

Around 4 million children undergo inpatient surgery in the United States each year, however little is known about the impact of surgery and postoperative pain on children's health-related quality of life (HRQOL) during the weeks and months after surgery. We measured pain and HRQOL in a large, heterogeneous pediatric postsurgical population from baseline to 1-month follow-up. Over a 20-month period, parents of 915 children age 2 to 18 years (mean = 9.6 years), 50% male, 56% white, admitted to surgical services at a children's hospital enrolled in the study. Parent participants reported on sociodemographics, child HRQOL, and pain characteristics at baseline and 1 month after discharge. Although most of the children recovered to baseline by 1 month after hospital discharge, 23% of children had a significant decline in HRQOL. Logistic regression analyses found that increasing child age (odds ratio = 2.1 for age 13-18 years) and the presence of moderate-severe postsurgical pain at 1 month (odds ratio = 5.7) were significantly associated with deterioration in HRQOL from baseline to 1-month follow-up (P < .05 for each variable). Although HRQOL returns to the baseline level for most children, a sizeable proportion have significant deterioration in HRQOL associated with continued postsurgical pain at 1 month after hospital discharge from surgery.

PERSPECTIVE

This study addresses an important gap in the literature, examining pain and health-related quality of life in a broad population of children undergoing a wide range of inpatient surgeries. Evaluation of inpatient health services from a patient and family perspective is essential in evaluating outcomes of surgical care.

The Effect of Institutional Volume on Complications and Their Impact on Mortality After Pediatric Heart Transplantation

BACKGROUND

This study evaluated the potential association of institutional volume with survival and mortality subsequent to major complications in a modern cohort of pediatric patients after orthotopic heart transplantation (OHT).

METHODS

The United Network of Organ Sharing database was queried for pediatric patients (aged ≤18 years) undergoing OHT between 2000 and 2010. Institutional volume was defined as the average number of transplants completed annually during each institution's active period and was evaluated as categoric and as a continuous variable. Logistic regression models were used to determine the effect of institutional volumes on postoperative outcomes, which included renal failure, stroke, rejection, reoperation, infection, and a composite complication outcome. Cox modeling was used to analyze the risk-adjusted effect of institutional volume on 30-day, 1-year, and 5-year mortality. Kaplan-Meier estimates were used to compare differences in unconditional survival.

RESULTS

A total of 3,562 patients (111 institutions) were included and stratified into low-volume (<6.5 transplants/year, 91 institutions), intermediate-volume (6.5 to 12.5 transplants/year, 12 institutions), and high-volume (>12.5 transplants/year, 8 institutions) tertiles. Unadjusted survival was significantly different at 30 days (p = 0.0087) in the low-volume tertile (94.2%; 95% confidence interval, 92.7% to 95.4%) compared with the high-volume tertile (96.8%; 95% confidence interval, 95.7% to 97.7%). No difference was observed at 1 or 5 years. Risk-adjusted Cox modeling demonstrated that low-volume institutions had an increased rate of mortality at 30 days (hazard ratio, 1.91; 95% confidence interval, 1.02 to 3.59; p = 0.044), but not at 1 or 5 years. High-volume institutions had lower incidences of postoperative complications than low-volume institutions (30.3% vs 38.4%, p < 0.001). Despite this difference in the rate of complications, survival in patients with a postoperative complication was similar across the volume tertiles.

CONCLUSIONS

No association was observed between institutional volume and adjusted or unadjusted long-term survival. High-volume institutions have a significantly lower rate of postoperative complications after pediatric OHT. This association does not correlate with increased subsequent mortality in low-volume institutions. Given these findings, strategies integral to the allocation of allografts in adult transplantation, such as regionalization of care, may not be as relevant to pediatric OHT.

Is There an Increasing Regionalization of Surgical Repair of Craniosynostosis Procedures Into Teaching Hospitals? Implications of Regionalization

Objective The objective of the present study is to examine whether surgical repairs for craniosynostosis have been regionalized to teaching hospitals over the 8-year period from 2003 to 2010. Design Retrospective analysis of hospital discharge database. Setting Nationwide Inpatient Sample for years 2003 to 2010. All patients aged up to 3 years who had a surgical repair for craniosynostosis were selected. Interventions Surgical repair for craniosynostosis. Main Outcome Measures Performance of surgery in a teaching hospital. Results During the study period (years 2003 to 2010), a total of 19,417 patients aged up to 3 years underwent a surgical repair for craniosynostosis. The number of surgical procedures increased during the study period. It ranged from 1628 procedures in year 2003 to 3001 procedures during 2010. Data show that 83.3% of all procedures in 2003 were performed in teaching hospitals; whereas, 97.5% of procedures in 2010 were performed in teaching hospitals. Following adjustment for patient-level factors, year 2010 was associated with increased odds of having the surgical procedures performed in a teaching hospital as opposed to a nonteaching hospital when compared with year 2003 (odds ratio = 10.43, 95% confidence interval, 1.10 to 98.98; P = .04). Conclusions An increasing proportion of surgical repairs of craniosynostosis are performed in teaching hospitals, suggesting there is an increasing concentration of these complex surgical procedures in select centers. As more longitudinal data become available, the relative benefits and drawbacks associated with regionalization of surgical repairs of craniosynostosis should be examined.

Hospital Surgical Volume and Associated Postoperative Complications of Pediatric Urological Surgery in the United States

PURPOSE

Hospital and provider surgical volume have been increasingly linked to surgical outcomes. However, this topic has rarely been addressed in children. We investigated whether hospital surgical volume impacts complication rates in pediatric urology.

MATERIALS AND METHODS

We retrospectively reviewed the Nationwide Inpatient Sample (1998 to 2011) for pediatric (18 years or younger) hospitalizations for urological procedures. We used ICD-9-CM codes to identify elective urological interventions and NSQIP® postoperative in hospital complications. Annual hospital surgical volume was calculated and dichotomized as high volume (90th percentile or above) or non-high volume (below 90th percentile).

RESULTS

We identified 158,805 urological admissions (114,634 high volume and 44,171 non-high volume hospitals). Of the hospitals 75% recorded fewer than 5 major pediatric urology cases performed yearly. High volume hospitals showed treatment of significantly younger patients (mean 5.4 vs 9.6 years, p < 0.001) and were more likely to be teaching hospitals (93% vs 71%, p < 0.001). The overall rate of NSQIP identified postoperative complications was higher at non-high volume vs high volume hospitals (11.6% vs 9.3%, p = 0.003). After adjusting for confounding effects patients treated at non-high volume hospitals remained more likely to suffer multiple NSQIP tracked postoperative complications, including acute renal failure (OR 1.4, p = 0.04), urinary tract infection (OR 1.3, p = 0.01), postoperative respiratory complications (OR 1.5, p = 0.01), systemic sepsis (OR 2.0, p ≤ 0.001), postoperative bleeding (OR 2.5, p < 0.001) and in hospital death (OR 2.2, p = 0.007).

CONCLUSIONS

Urological procedures performed in children at non-high volume hospitals were associated with an increased risk of in hospital, NSQIP identified postoperative complications, including a small but significant increase in postoperative mortality, mostly following nephrectomy and percutaneous nephrolithotomy.