Using evidence-based medicine principles to improve quality of patient care in pediatric surgery

A pilot investigation of a Pediatric Surgery Journal Club

BACKGROUND

The CanMEDS competency "scholar" encompasses the creation, dissemination, application, and translation of medical knowledge. We hypothesize that a structured journal club (JC) for pediatric surgical trainees would meet these objectives in an enjoyable and long-lasting manner.

METHODS

A JC involving two pediatric surgery training programs was created with each session focusing on a specific study design. Pre-tests/post-tests were administered before/after each session with durability of learning assessed during the following session. Metrics analyzed included participant satisfaction and an appraisal of evidence-based medicine (EBM) principals. Test results were analyzed using the paired T-test with p<0.05 considered significant.

RESULTS

On average, 14 participants attended each session, with all trainees present (4). While participants believed they understood EBM principles, 40% were unfamiliar with question formulation, 48% were unfamiliar with critical appraisal tools, and 60% had not appraised an article within the previous year. Pre-test to post-test comparison yielded an improvement in mean score (20=perfect score): 10.8 to 16.9, p<0.01. Measures of participant satisfaction were uniformly positive.

CONCLUSION

A structured Pediatric Surgery Journal Club addresses scholarly training objectives in a highly satisfactory manner and yields durable learning. A web-based curriculum based on this model could serve as an important educational tool for trainees and attending staff alike.

Optimizing the role of imaging in appendicitis

Acute appendicitis is the most common acute abdominal condition that requires surgical intervention in childhood. From the diagnostic performance perspective, computed tomography (CT) has a significantly higher sensitivity than does ultrasound (US) for diagnosing appendicitis in children; from the safety perspective, however, one should consider the radiation associated with CT, especially in children. There is strong evidence supporting improved patient outcomes in children with suspected acute appendicitis who undergo CT scanning. Nevertheless, we should keep in mind that for a single abdominal CT study in a 5-year-old child, the lifetime risk of radiation-induced cancer would be 26.1 per 100,000 in female and 20.4 per 100,000 in male patients, based on probabilistic models designed with data from atomic bomb survivors. An integrated clinical-imaging approach, applying clinical scores that are able to predict which children with acute abdominal pain do or do not have a high probability of presenting with appendicitis may improve the effectiveness of the imaging diagnosis of appendicitis at the hospital level. Such an approach could avoid exposure of children who at low risk for appendicitis to unnecessary diagnostic tests and eventually, to radiation.

The CDH Study Group and advances in the clinical care of the patient with congenital diaphragmatic hernia

Congenital diaphragmatic hernia (CDH) occurs in 1 of every 2000 to 4000 births and accounts for 8% of all major congenital anomalies. Recurrence risk for a subsequent pregnancy is estimated at 2%. The mortality rate for CDH when diagnosed antenatally, varies with fetal age and with the presence or absence of hydramnios and degree of pulmonary hypoplasia. The prognosis has improved dramatically in recent years, primarily due to advances in neonatal and surgical interventions. Neonatal survival rates with an antenatal diagnosis now exceed 80% in some centers. Treatment for infants with CDH reflects other pediatric surgical problems in that a majority of the clinical research that shapes treatment is retrospective in nature. Because CDH is a relatively rare disease, using a compilation of cases, such as the CDH database provides, greatly aids our understanding of this disease process. Moreover, the application of a quality assessment scale provides the practitioner with a knowledge base to critically evaluate the published retrospective data.

Toward evidence-based best practices in neonatal surgical care-I: The Canadian NICU Network

BACKGROUND/PURPOSE

The Canadian Neonatal Network collects clinical data prospectively on every admission to each of its 17 tertiary level units in Canada. The purpose of this study was to interrogate the network database to determine case volumes, outcomes, and resource utilization for several neonatal surgical conditions.

METHODS

The network database was used to measure a population-based, profile of incidence, outcome and resource utilization over a 22-month period for the following International Classification of Diseases, Ninth Revision (ICD-9) diagnostic codes: 741, spina bifida; 748.4, congenital cystic lung disease; 750.3, tracheoesophageal fistula; 751.1, atresia/stenosis of small intestine; 751.2, atresia/stenosis of large intestine/imperforate anus; 751.3, Hirschsprung's disease; 756.6, anomalies of the diaphragm; 756.7, anomalies of the abdominal wall. Also, all infants receiving extracorporeal membrane oxygenation (ECMO) during the study period were identified.

RESULTS

Case volumes corresponding to each diagnostic code were as follows: 741 (104), 748.4 (12), 750.3 (124), 751.1 (142), 751.2 (121), 751.3 (67), 756.6 (88), 756.7 (151), ECMO cases (28). As a group, infants in the database who required major surgery consumed a disproportionate share of resources and had poorer outcomes than those who did not require major surgery.

CONCLUSIONS

The Canadian Neonatal Network database enables population-based outcomes analysis for specific diagnoses, which, if supplemented by additional pre-and postnatal data fields for surgical conditions, could contribute to the determination of evidence-based best practices for these patients.