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Chang JJ, Buchanan P, Geremakis C, Sheikh K, Mitchell RB. Cost analysis of tonsillectomy in children using medicaid data. J Pediatr 2014; 164:1346-51.e1. [PMID: 24631119 DOI: 10.1016/j.jpeds.2014.01.055] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2013] [Revised: 12/31/2013] [Accepted: 01/27/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To evaluate the cost-effectiveness of adenotonsillectomy (T&A) for adenotonsillar hypertrophy and recurrent tonsillitis through the use of Missouri Medicaid data. STUDY DESIGN Children ages 2-16 years who had a diagnosis of adenotonsillar hypertrophy (based on medical claim codes) in 2006 (n = 4276) were included in this population-based study. The main outcome was direct total costs paid by Medicaid. Costs 2 years before and after T&A were compared in children who underwent surgical intervention with those who did not as well as costs comparison pre- and post-T&A. Wilcoxon rank-sum or Wilcoxon Signed-rank test was used for costs comparisons. RESULTS Children with adenotonsillar hypertrophy who underwent T&A were significantly less likely to be African American. They had more adenotonsillar infections before undergoing T&A and greater total costs (median costs $2313 vs. $1945; P = .009). The median costs were $1228 pre-T&A, compared with $823 post-T&A (P < .0001). This reduction in costs of $405 (33%) compares with a median cost of the procedure of $1088. The reduction in costs was mostly because of less antibiotic use and outpatient visits. CONCLUSIONS African American children have fewer T&A procedures for adenotonsillar hypertrophy than white children, which represents an unexplained racial disparity. Children with adenotonsillar hypertrophy who underwent T&A compared with those who did not had more adenotonsillar infections and greater health care costs. T&A leads to a reduction in costs that, after 2 years, is 37% of the costs of the procedure. Future studies should examine the effects of demographics, obesity, and disease severity on health care costs in children with adenotonsillar hypertrophy.
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Affiliation(s)
- Jen Jen Chang
- Department of Epidemiology, College for Public Health and Social Justice, Saint Louis University, St. Louis, MO.
| | - Paula Buchanan
- Center for Outcome Research, Saint Louis University, St. Louis, MO
| | | | - Kazim Sheikh
- Department of Health Policy and Management, University of Kansas Medical School, Kansas City, KS
| | - Ron B Mitchell
- Southwestern and Children's Medical Center Dallas, University of Texas, Dallas, TX
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Sømme S, Bronsert M, Morrato E, Ziegler M. Frequency and variety of inpatient pediatric surgical procedures in the United States. Pediatrics 2013; 132:e1466-72. [PMID: 24276846 DOI: 10.1542/peds.2013-1243] [Citation(s) in RCA: 134] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Pediatric surgical procedures are being performed in a variety of hospitals with large differences in surgical volume. We examined the frequency and variety of inpatient pediatric surgical procedures in the United States by hospital type and geographic region using a nationally representative sample. METHODS The 2009 Kids' Inpatient Database for patients <18 years old was used to calculate surgical frequencies by using International Classification of Diseases, Ninth Revision, Clinical Modification, (ICD-9-CM) codes. We performed stratified analysis by hospital type (free-standing children's hospital, children's unit within an adult hospital, and general hospital) and geographic region (South, West, Midwest, Northeast) to compare frequencies of surgical procedures. RESULTS A total of 216 081 procedures were projected for 2009 with the top 20 procedures accounting for >90% of cases. As many as 40% of all pediatric inpatient surgical procedures are being performed in adult general hospitals. Infrequent complex low-volume neonatal surgical procedures (pullthrough for Hirschsprung disease, surgery for malrotation, esophageal atresia repair, and diaphragmatic hernia repair) were 6.8 to 16 times more likely to occur in a children's hospital. Significant regional variation in procedure frequency rates occurred for appendectomy and cholecystectomy. CONCLUSIONS This report is the first to characterize pediatric surgical inpatient volume in the United States. Such data may influence the distribution of pediatric surgeons, number of trainees, and training curricula for pediatric surgeons, pediatricians, general surgeons and other surgical specialists who might operate on children. In addition, it raises the question of whether complex pediatric surgical procedures should preferably be performed at dedicated high volume children's hospitals.
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Affiliation(s)
- Stig Sømme
- Children's Hospital Colorado, B323, 13123 E 16th Ave, Aurora, CO 80045.
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Heng SJ, Low L, MacKinnon JR, Lavy T, Dutton GN. Evaluation of the utility of hospital databases to provide data in assessing the quality of strabismus surgery. Scott Med J 2013; 58:104-8. [PMID: 23728756 DOI: 10.1177/0036933013482641] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
AIMS AND BACKGROUND Rates of re-operation, which may be related to an unsatisfactory surgical outcome, can provide a long-term index of the quality of strabismus surgery. This study aims to evaluate the utility of the Scottish Morbidity Records (SMR1) in determining nature and rates of re-operation for strabismus at the Royal Hospital for Sick Children (RHSC), Glasgow. METHODS SMR1 data on strabismus surgery performed on children aged between 0 and 17 years at the RHSC, Glasgow, between January 2000 and March 2009 were analysed. RESULTS In total, 1376 strabismus procedures were carried out on 1274 individuals. The median time between first and subsequent procedures was 19 months; the commonest reasons being under-correction or recurrence. The Kaplan-Meier rate of undergoing re-operation was 7.4% after 9 years with a 95% confidence interval of 5.4-9.9%. CONCLUSIONS The SMR1 is a useful source of hospital-based and population data. With supplementation from parallel databases, routine administrative databases like the SMR1 can provide better quality data to inform practice.
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Affiliation(s)
- S J Heng
- Faculty of Medicine, Imperial College London, UK
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Bruny J, Ziegler MM. Historical development of pediatric surgical quality: the first 100 years. Adv Pediatr 2013; 60:281-94. [PMID: 24007849 DOI: 10.1016/j.yapd.2013.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Jennifer Bruny
- Department of Surgery, Children's Hospital of Colorado, University of Colorado School of Medicine, 13123 East 16th Avenue, Aurora, CO 80045, USA.
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Bruny JL, Hall BL, Barnhart DC, Billmire DF, Dias MS, Dillon PW, Fisher C, Heiss KF, Hennrikus WL, Ko CY, Moss L, Oldham KT, Richards KE, Shah R, Vinocur CD, Ziegler MM. American College of Surgeons National Surgical Quality Improvement Program Pediatric: a beta phase report. J Pediatr Surg 2013; 48:74-80. [PMID: 23331796 DOI: 10.1016/j.jpedsurg.2012.10.019] [Citation(s) in RCA: 135] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2012] [Accepted: 10/13/2012] [Indexed: 11/19/2022]
Abstract
PURPOSE The American College of Surgeons (ACS) National Surgical Quality Improvement Program Pediatric (NSQIP-P) expanded to beta phase testing with the enrollment of 29 institutions. Data collection and analysis were aimed at program refinement and development of risk-adjusted models for inter-institutional comparisons. METHODS Data from the first full year of beta-phase NSQIP-P were analyzed. Patient accrual used ACS-NSQIP methodology tailored to pediatric specialties. Preliminary risk adjusted modeling for all pediatric and neonatal operations and pediatric (excluding neonatal) abdominal operations was performed for all cause morbidity (other than death) and surgical site infections (SSI) using hierarchical logistic regression methodology and eight predictor variables. Results were expressed as odds ratios with 95% confidence intervals. RESULTS During calendar year 2010, 29 institutions enrolled 37,141 patients. 1644 total CPT codes were entered, of which 456 accounted for 90% of the cases. 450 codes were entered only once (1.2% of cases). For all cases, overall mortality was 0.25%, overall morbidity 7.9%, and the SSI rate 1.8%. For neonatal cases, mortality was 2.39%, morbidity 18.7%, and the SSI rate 3%. For the all operations model, risk-adjusted morbidity institutional odds ratios ranged 0.48-2.63, with 9/29 hospitals categorized as low outliers and 9/29 high outliers, while risk-adjusted SSI institutional odds ratios ranged 0.36-2.04, with 2/29 hospitals low outliers and 7/29 high outliers. CONCLUSION This report represents the first risk-adjusted hospital-level comparison of surgical outcomes in infants and children using NSQIP-P data. Programmatic and analytic modifications will improve the impact of this program as it moves into full implementation. These results indicate that NSQIP-P has the potential to serve as a model for determining risk-adjusted outcomes in the neonatal and pediatric population with the goal of developing quality improvement initiatives for the surgical care of children.
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Affiliation(s)
- Jennifer L Bruny
- Division of Pediatric Surgery, Department of Surgery, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO, USA.
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Kennedy A, Bakir C, Brauer CA. Quality indicators in pediatric orthopaedic surgery: a systematic review. Clin Orthop Relat Res 2012; 470:1124-32. [PMID: 21912995 PMCID: PMC3293946 DOI: 10.1007/s11999-011-2060-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The ability to measure health system quality has become a priority for governments, the private sector, and the public. Quality indicators (QIs) refer to clear, measurable items related to outcomes. The use of QIs can initiate local quality improvement and track changes in quality over time as interventions are implemented. QUESTIONS/PURPOSES We identified existing evidence-based indicators of quality pediatric orthopaedic care and evaluated published QIs that may be applicable to pediatric orthopaedic care. SEARCH STRATEGY Using five standard search engines we searched the literature using terms such as "quality indicators," "orthopaedic surgery," and "pediatric." Study selection was performed in a stepwise manner, first by title, then abstract, and then full-text review. Of the 604 citations identified, 13 articles were selected for inclusion. Eight papers included only pediatric patients. RESULTS The most commonly reported indicator was mortality followed by postoperative complications. Reoperation and readmission rates were also reported along with patient-centered QIs, although with less frequency. CONCLUSION Although mortality and postoperative complications were the most frequently reported QIs, concern for their applicability was raised because of their relative infrequency in pediatrics. Patient-centered QIs appear to be the most useful tools reported, although their use is somewhat limited in the published literature. Although there are benefits and drawbacks to all reported QIs, patient-centered and surgeon-defined outcomes along with cost-effectiveness have important roles in evaluating the quality of pediatric orthopaedic care.
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Affiliation(s)
- Angeliki Kennedy
- Division of Orthopaedic Surgery, Faculty of Medicine, University of Calgary, Calgary, AB Canada
| | - Christina Bakir
- Division of Orthopaedic Surgery, Faculty of Medicine, University of Calgary, Calgary, AB Canada
| | - Carmen A. Brauer
- Division of Orthopaedic Surgery, Faculty of Medicine, University of Calgary, Calgary, AB Canada
- Department of Surgery, University of Calgary, Alberta Children’s Hospital, 2888 Shaganappi Trail NW, Calgary, AB T3B 6A8 Canada
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Abstract
BACKGROUND Comparative evaluation of surgical quality among hospitals must improve outcome and efficiency, and reduce medical costs. Reoperation after colorectal surgery is a consequence of surgical complications and therefore considered a quality-of-care indicator. With respect to the mortality rate, the 1-year mortality may be a more meaningful figure than in-hospital mortality, because it also reflects the impact of surgical complications beyond discharge. OBJECTIVE The aim of our study was to evaluate the 1-year mortality after colorectal surgery and to identify predicting factors. DESIGN This study was a retrospective analysis from our colorectal surgery database. PATIENTS All patients who underwent elective colorectal surgery from 2005 to 2008 were included. MAIN OUTCOME MEASURES Both univariate and multivariate analysis were performed to identify predicting factors. The following variables were analyzed: age, operative risk according to the ASA class, Charlson-Age Comorbidity Index, indication for and type of resection, primary anastomosis, tumor staging, anastomotic leakage, and reoperation. RESULTS For 743 consecutive patients, the 1-year mortality rate was 6.9%. Patients were operated on mainly because of colorectal cancer (n = 537; 72%). The rate of reoperation and in-hospital mortality was 12.8% and 2.4%. Univariate survival analysis demonstrated that ASA class, age, Charlson-Age Comorbidity Index, reoperation, and stage of disease were independent predictors of 1-year mortality. Multivariate analysis showed that ASA class (P = .020; HR 1.69), age (P = .015; HR 2.08) and reoperation (P = .001; HR 2.72) are directly correlated with 1-year mortality. LIMITATIONS Both patients with benign diseases and colorectal cancer are included. Furthermore, no clear guidelines on whether to perform a reoperation were available. CONCLUSION One-year mortality after colorectal surgery is independently predicted by ASA class, age, and reoperation. Our results underline the value of the 1-year mortality rate and the reoperation rate as parameters for quality assessment in colorectal surgery.
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Cathcart P, Connolly S, Walton T, Costello AJ, Murphy DG. Re: Administrative data sets are inaccurate for assessing functional outcomes after radical prostatectomy: M. K. Tollefson, M. T. Gettman, R. J. Karnes and I. Frank J Urol 2011; 185: 1686-1690. J Urol 2011; 186:2133-4; author reply 2134. [PMID: 21944984 DOI: 10.1016/j.juro.2011.07.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2011] [Indexed: 10/17/2022]
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Raval MV, Dillon PW, Bruny JL, Ko CY, Hall BL, Moss RL, Oldham KT, Richards KE, Vinocur CD, Ziegler MM. American College of Surgeons National Surgical Quality Improvement Program Pediatric: A Phase 1 Report. J Am Coll Surg 2011; 212:1-11. [DOI: 10.1016/j.jamcollsurg.2010.08.013] [Citation(s) in RCA: 148] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2010] [Revised: 08/20/2010] [Accepted: 08/23/2010] [Indexed: 11/29/2022]
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Pediatric American College of Surgeons National Surgical Quality Improvement Program: feasibility of a novel, prospective assessment of surgical outcomes. J Pediatr Surg 2011; 46:115-21. [PMID: 21238651 DOI: 10.1016/j.jpedsurg.2010.09.073] [Citation(s) in RCA: 164] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2010] [Accepted: 09/30/2010] [Indexed: 12/21/2022]
Abstract
PURPOSE The American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) provides validated assessment of surgical outcomes. This study reports initiation of an ACS NSQIP Pediatric at 4 children's hospitals. METHODS From October 2008 to June 2009, 121 data variables were prospectively collected for 3315 patients, including 30-day outcomes and tailoring the ACS NSQIP methodology to children's surgical specialties. RESULTS Three hundred seven postoperative complications/occurrences were detected in 231 patients representing 7.0% of the study population. Of the patients with complications, 175 (75.7%) had 1, 39 (16.9%) had 2, and 17 (7.4%) had 3 or more complications. There were 13 deaths (0.39%) and 14 intraoperative occurrences (0.42%) detected. The most common complications were infection, 105 (34%) (SSI, 54; sepsis, 31; pneumonia, 13; urinary tract infection, 7); airway/respiratory events, 27 (9%); wound disruption, 18 (6%); neurologic events, 8 (3%) (nerve injury, 4; stroke/vascular event, 2; hemorrhage, 2); deep vein thrombosis, 3 (<1%); renal failure, 3 (<1%); and cardiac events, 3 (<1%). Current sampling captures 17.5% of cases across institutions with unadjusted complication rates ranging from 6.8% to 10.2%. Completeness of data collection for all variables exceeded 95% with 98% interrater reliability and 87% of patients having full 30-day follow-up. CONCLUSION These data represent the first multiinstitutional prospective assessment of specialty-specific surgical outcomes in children. The ACS NSQIP Pediatric is poised for institutional expansion and future development of risk-adjusted models.
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Adjusted or unadjusted outcomes. Am J Surg 2009; 198:S28-35. [DOI: 10.1016/j.amjsurg.2009.08.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2009] [Revised: 07/23/2009] [Accepted: 08/03/2009] [Indexed: 12/19/2022]
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Effect of subjective preoperative variables on risk-adjusted assessment of hospital morbidity and mortality. Ann Surg 2009; 249:682-9. [PMID: 19300217 DOI: 10.1097/sla.0b013e31819eda21] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To examine the influence of American Society of Anesthesiologists Physical Status Classification (ASA) and preoperative Functional Health Status (FHS) variables on risk-adjusted estimates of surgical quality and to assess whether classifications are inflated at some hospitals. BACKGROUND ASA and FHS are influential in risk-adjusted comparisons of surgical quality. However, because ASA and FHS are subjective they can be inflated, making patients appear more ill than they actually are, and crediting hospitals for a sicker patient population. METHODS We identified 28,751 colorectal surgery patients at 170 hospitals participating in the American College of Surgeon's National Surgical Quality Improvement Program (ACS NSQIP) during 2006 to 2007. Logistic regression models were developed for morbidity and mortality with and without inclusion of ASA and FHS. Hospital quality rankings from the different models were compared. RESULTS Morbidity and mortality rates were 24.3% and 3.9%, respectively. Percents of patients in ASA classes I through V were 3.3%, 46.4%, 41.5%,8.3%, and 0.7% and that were independent or partially or totally dependent were 89.2%, 7.2%, and 3.6%, respectively. Models that included ASA and FHS exhibited slightly better fit (Hosmer-Lemshow statistic) and discrimination(c-statistic) than models without both these variables, though magnitudes of differences were consistent with chance. There was inconsistent evidence for improper assignment of ASA and FHS. CONCLUSIONS The small improvements in model quality when both ASA and FHS are present versus absent, suggest that they make a unique contribution to assessing severity of preoperative risk. With little indication that these subjective variables are subject to an important level of institutional bias, it is appropriate that they be used to assess risk-adjusted surgical quality. Periodic monitoring for inappropriate inflation of ASA status is warranted.
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The innovation of success: the pediatric surgery and APSA response to "disruptive technologies". J Pediatr Surg 2009; 44:1-12. [PMID: 19159712 DOI: 10.1016/j.jpedsurg.2008.10.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2008] [Accepted: 10/07/2008] [Indexed: 11/23/2022]
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