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Channaoui A, de Magnée C, Tambucci R, Bonaccorsi-Riani E, Pirotte T, Magasich-Airola N, Detaille T, Houtekie L, Menten R, Dumitriu D, van den Hove M, Baldin P, Smets F, Scheers I, Jannone G, Sokal E, Stephenne X, Reding R. Failure to Rescue Pediatric Recipients of Living Donor Liver Transplantation: A Single-Center Study of Technical Complications in 500 Primary Grafts. Pediatr Transplant 2024; 28:e14861. [PMID: 39320008 DOI: 10.1111/petr.14861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2024] [Revised: 08/28/2024] [Accepted: 09/08/2024] [Indexed: 09/26/2024]
Abstract
BACKGROUND The concept of failure to rescue (FTR) has been used to evaluate the quality of care in several surgical specialties but has not been well-studied after living donor liver transplantation (LDLT) in children. METHODS This study retrospectively reviewed 500 pediatric LDLT performed at a single center between 1993 and 2022. The recipient outcomes were assessed by means of patient and graft survival rates, retransplantation rates, and arterial/portal/biliary complication rates. Graft and patient losses secondary to these complications were calculated regarding FTR for patients (FTRp) and grafts (FTRg). RESULTS Overall 1- and 5-year patient survival rates were 94.5% and 92.1%, respectively, the corresponding figures for graft survival being 92.7% and 89.8%. One-year hepatic artery complication rate was 3.6% (n = 18 cases), the respective rates for portal vein complications and biliary complications being 5.7% (n = 57) and 15.6% (n = 101). One-year FTRp rates for hepatic artery thrombosis, portal vein thrombosis, anastomotic biliary stricture, and intrahepatic biliary stricture were 28.6%, 9.4%, 3.6%, and 0%, respectively. The corresponding FTRg rates being 21.4%, 6.3%, 0%, and 36.4%. CONCLUSION Such novel analytical method may offer valuable insights for optimizing quality of care in pediatric LDLT.
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Affiliation(s)
- Aniss Channaoui
- Pediatric Surgery and Transplant Unit, Cliniques Universitaires Saint-Luc, UCLouvain, Brussels, Belgium
| | - Catherine de Magnée
- Pediatric Surgery and Transplant Unit, Cliniques Universitaires Saint-Luc, UCLouvain, Brussels, Belgium
| | - Roberto Tambucci
- Pediatric Surgery and Transplant Unit, Cliniques Universitaires Saint-Luc, UCLouvain, Brussels, Belgium
| | | | - Thierry Pirotte
- Department of Anesthesiology, Cliniques Universitaires Saint-Luc, UCLouvain, Brussels, Belgium
| | - Natalia Magasich-Airola
- Department of Anesthesiology, Cliniques Universitaires Saint-Luc, UCLouvain, Brussels, Belgium
| | - Thierry Detaille
- Pediatric Intensive Care Unit, Cliniques Universitaires Saint-Luc, UCLouvain, Brussels, Belgium
| | - Laurent Houtekie
- Pediatric Intensive Care Unit, Cliniques Universitaires Saint-Luc, UCLouvain, Brussels, Belgium
| | - Renaud Menten
- Pediatric Radiology Unit, Cliniques Universitaires Saint-Luc, UCLouvain, Brussels, Belgium
| | - Dana Dumitriu
- Pediatric Radiology Unit, Cliniques Universitaires Saint-Luc, UCLouvain, Brussels, Belgium
| | - Marguerite van den Hove
- Pediatric Surgery and Transplant Unit, Cliniques Universitaires Saint-Luc, UCLouvain, Brussels, Belgium
| | - Pamela Baldin
- Department of Pathology, Cliniques Universitaires Saint-Luc, UCLouvain, Brussels, Belgium
| | - Françoise Smets
- Division of Pediatric Gastroenterology and Hepatology, Cliniques Universitaires Saint-Luc, UCLouvain, Brussels, Belgium
| | - Isabelle Scheers
- Division of Pediatric Gastroenterology and Hepatology, Cliniques Universitaires Saint-Luc, UCLouvain, Brussels, Belgium
| | - Giulia Jannone
- Division of Pediatric Gastroenterology and Hepatology, Cliniques Universitaires Saint-Luc, UCLouvain, Brussels, Belgium
| | - Etienne Sokal
- Division of Pediatric Gastroenterology and Hepatology, Cliniques Universitaires Saint-Luc, UCLouvain, Brussels, Belgium
| | - Xavier Stephenne
- Division of Pediatric Gastroenterology and Hepatology, Cliniques Universitaires Saint-Luc, UCLouvain, Brussels, Belgium
| | - Raymond Reding
- Pediatric Surgery and Transplant Unit, Cliniques Universitaires Saint-Luc, UCLouvain, Brussels, Belgium
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Mehl SC, Portuondo JI, Tian Y, Raval MV, Shah SR, Vogel AM, Wesson D, Massarweh NN. Utility of Hospital Failure to Rescue for Analyzing Variation in Pediatric Postoperative Mortality. Pediatr Crit Care Med 2024; 25:e64-e72. [PMID: 37695135 DOI: 10.1097/pcc.0000000000003363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/12/2023]
Abstract
OBJECTIVES To evaluate the association between pediatric hospital performances in terms of failure to rescue (FTR), defined as postoperative mortality after a surgical complication, and mortality among patients without a surgical complication. DESIGN Retrospective cohort study. SETTING Forty-eight academic, pediatric hospitals; data obtained from Pediatric Health Information System database (Child Health Corporation of America, Shawnee Mission, KS) (2012-2020). PATIENTS Children who underwent at least one of 57 high-risk operations associated with significant postoperative mortality. EXPOSURES Hospitals were stratified into quintiles of reliability adjusted FTR (lower than average FTR in quintile 1 [Q1], higher than average FTR in quintile 5 [Q5]). Multivariable hierarchical regression was used to evaluate the association between hospital FTR performance and mortality among patients who did not have a surgical complication. MEASUREMENTS AND MAIN RESULTS Among 203,242 children treated across 48 academic hospitals, the complication and overall postoperative mortality rates were 8.8% and 2.3%, respectively. Among patients who had a complication, the FTR rate was 8.8%. Among patients who did not have a complication, the mortality rate was 1.7%. There was a 6.5-fold increase in reliability adjusted FTR between the lowest and highest performing hospitals (lowest FTR hospital-2.7%; 95% CI [1.6-3.9]; highest FTR hospital-17.8% [16.8-18.8]). Complex chronic conditions were highly prevalent across hospitals (Q1, 72.7%; Q2, 73.8%; Q3, 72.2%; Q4, 74.0%; Q5, 74.8%; trend test p < 0.01). Relative to Q1 hospitals, the odds of mortality in the absence of a postoperative complication significantly increased by 33% at Q5 hospitals (odds ratio 1.33; 95% CI [1.07-1.66]). This association was consistent when limited to patients with a complex chronic condition and neonates. CONCLUSION FTR may be a useful and valid surgical quality measure for pediatric surgery, even when considering patients without a postoperative complication. These findings suggest practices and processes for preventing FTR at high performing pediatric hospitals might help mitigate the risk of postoperative mortality even in the absence of a postoperative complication.
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Affiliation(s)
- Steven C Mehl
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX
| | - Jorge I Portuondo
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Yao Tian
- Surgical Outcomes and Quality Improvement Center, Center for Health Services and Outcomes Research, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Mehul V Raval
- Surgical Outcomes and Quality Improvement Center, Center for Health Services and Outcomes Research, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Sohail R Shah
- Pediatrix Surgery of Houston, Department of Surgery, Houston, TX
| | - Adam M Vogel
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX
| | - David Wesson
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX
| | - Nader N Massarweh
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX
- Surgical Outcomes and Quality Improvement Center, Center for Health Services and Outcomes Research, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
- Pediatrix Surgery of Houston, Department of Surgery, Houston, TX
- Surgical and Perioperative Care, Atlanta VA Health Care System, Decatur, GA
- Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine, Atlanta, GA
- Department of Surgery, Morehouse School of Medicine, Atlanta, GA
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Mehl SC, Portuondo JI, Tian Y, Raval MV, Shah SR, Vogel AM, Wesson D, Massarweh NN. Hospital Variation in Mortality After Inpatient Pediatric Surgery. Ann Surg 2023; 278:e598-e604. [PMID: 36259769 DOI: 10.1097/sla.0000000000005729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The aim was to determine the association between risk adjusted hospital perioperative mortality rates, postoperative complications, and failure to rescue (FTR) after inpatient pediatric surgery. BACKGROUND FTR has been identified as a possible explanatory factor for hospital variation in perioperative mortality in adults. However, the extent to which this may be the case for hospitals that perform pediatric surgery is unclear. METHODS The Pediatric Health Information System database (2012-2020) was used to identify patients who underwent one of 57 high-risk operations associated with significant perioperative mortality (n=203,242). Academic, pediatric hospitals (n=48) were stratified into quintiles based on risk adjusted inpatient mortality [lower than average, quintile 1 (Q1); higher than average, quintile 5 (Q5)]. Multivariable hierarchical regression was used to evaluate the association between hospital mortality rates, complications, and FTR. RESULTS Inpatient mortality, complication, and FTR rates were 2.3%, 8.8%, and 8.8%, respectively. Among all patients who died after surgery, only 34.1% had a preceding complication (Q1, 36.1%; Q2, 31.5%; Q3, 34.7%; Q4, 35.7%; Q5, 32.2%; trend test, P =0.49). The rates of observed mortality significantly increased across hospital quintiles, but the difference was <1% (Q1, 1.9%; Q5; 2.6%; trend test, P <0.01). Relative to Q1 hospitals, the odds of complications were not significantly increased at Q5 hospitals [odds ratio (OR): 1.02 (0.87-1.20)]. By comparison, the odds of FTR was significantly increased at Q5 hospitals [OR: 1.60 (1.30-1.96)] with a dose-response relationship across hospital quintiles [Q2-OR: 0.99 (0.80-1.22); Q3-OR: 1.26 (1.03-1.55); Q4-OR: 1.33 (1.09-1.63)]. CONCLUSIONS The minority of pediatric surgical deaths are preceded by a postoperative complication, but variation in risk adjusted mortality across academic, pediatric hospitals may be partially explained by differences in the recognition and management of postoperative complications. Additional work is needed to identify children at greatest risk of postoperative death from perioperative complications as opposed to those at risk from pre-existing chronic conditions.
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Affiliation(s)
- Steven C Mehl
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
- Department of Surgery, Division of Pediatric Surgery, Texas Children's Hospital, Houston, TX
| | - Jorge I Portuondo
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Yao Tian
- Surgical Outcomes and Quality Improvement Center, Center for Health Services and Outcomes Research, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine; Chicago, IL
- Department of Surgery, Division of Pediatric Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Mehul V Raval
- Surgical Outcomes and Quality Improvement Center, Center for Health Services and Outcomes Research, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine; Chicago, IL
- Department of Surgery, Division of Pediatric Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Sohail R Shah
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
- Department of Surgery, Division of Pediatric Surgery, Texas Children's Hospital, Houston, TX
| | - Adam M Vogel
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
- Department of Surgery, Division of Pediatric Surgery, Texas Children's Hospital, Houston, TX
| | - David Wesson
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
- Department of Surgery, Division of Pediatric Surgery, Texas Children's Hospital, Houston, TX
| | - Nader N Massarweh
- Surgical and Perioperative Care, Atlanta VA Health Care System, Decatur, GA
- Department of Surgery, Division of Surgical Oncology, Emory University School of Medicine, Atlanta, GA
- Department of Surgery, Morehouse School of Medicine, Atlanta, GA
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Melhado CG, Kao E, Hogan-Schlientz J, Crane D, Shui AM, Stephens CQ, Evans L, Burd RS, Jensen AR. Interrater reliability of chart-based assessment of functional impairment after pediatric injury using the functional status scale. J Trauma Acute Care Surg 2023; 95:391-396. [PMID: 37012628 DOI: 10.1097/ta.0000000000003912] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023]
Abstract
BACKGROUND Functional impairment has been proposed as an alternative outcome for quality improvement in pediatric trauma. The functional status scale (FSS) has been used in studies of injured children, but has only been validated with resource-intensive in-person assessment. Implementation with retrospective chart-based FSS assessment would offer a simplified and scalable alternative. The purpose of this study was to evaluate interrater reliability of retrospective FSS assessment and to identify factors associated with unreliable assessment. METHODS A retrospective cohort of admissions to a Level I pediatric trauma center between July 2020 and June 2021 was analyzed. Two physicians and two nurse registrars reviewed charts to obtain measures of six FSS domains (mental status, sensory functioning, communication, motor functioning, feeding, and respiratory status) at discharge. Functional impairment was categorized by total FSS scores as good (6,7), mild impairment (8,9), moderate impairment (10-15), severe impairment (16-21), or very severe impairment (>21). Interrater reliability was assessed using intraclass correlation (ICC). Predictors of rater disagreement were evaluated using multivariable logistic regression. RESULTS The cohort included 443 children with a mean age of 7.4 years (standard deviation, 5.4 years) and median Injury Severity Score of 9 (interquartile range, 5-12). The median time per chart to assess FSS was 2 minutes (interquartile range, 1-2). Thirty-seven patients (8%) had functional impairment at discharge. Interrater reliability was excellent for total FSS score (ICC = 0.87) and good for FSS impairment categorization (ICC = 0.80). Rater disagreement of functional impairment categorization occurred in 14% of cases overall. Higher level of functional impairment and use of therapies (occupational and speech language therapy) were independently associated with more frequent rater disagreement. CONCLUSION Chart-based FSS assessment is feasible and reliable, but may require more detailed review for patients with higher level of impairment that require allied health therapy. Validation of chart-based assessment is needed before widespread implementation. LEVEL OF EVIDENCE Prognostic/Epidemiological, Level III.
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Affiliation(s)
- Caroline G Melhado
- From the Division of Pediatric Surgery (C.G.M., E.K., C.Q.S., L.E., A.R.J.), UCSF Benioff Children's Hospitals; Department of Surgery (C.G.M., E.K., C.Q.S., L.E., A.R.J.), University of California San Francisco, San Francisco; Trauma Program (J.H.-S., D.C., A.R.J.), UCSF Benioff Children's Hospital Oakland, Oakland; Department of Epidemiology & Biostatistics (A.M.S.), University of California San Francisco, San Francisco, California; and Division of Trauma and Burn Surgery (R.S.B.), Children's National Hospital, Washington, District of Columbia
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Mackow AK, Macias CG, Rangel SJ, Fallat ME. Children's surgery verification and value-based care in pediatric surgery. Semin Pediatr Surg 2023; 32:151277. [PMID: 37164817 DOI: 10.1016/j.sempedsurg.2023.151277] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
With the prevailing focus on increasing value in healthcare, understanding the different components of the value equation is of primary importance. Michael E. Porter's writings on the value agenda and the use of integrated practice units (IPUs) have provided easy correlation to adult disease entities with large populations sharing common pathways and providers in the diagnosis and care of these patients. In pediatric surgery, with smaller populations and larger numbers of rare or unique conditions and anatomic challenges, utilizing the concept of an IPU is more challenging. The literature has generally shown the improvements in quality of care through participation in various programs through the American College of Surgeons (ACS) such as trauma verification, or the National Surgical Quality Improvement Project (NSQIP), but that participation alone does not guarantee better outcomes. Use of these programs in conjunction with participation in quality collaboratives have tended to show favorable returns on investment for these programs. We seek to demonstrate how the Children's Surgery Verification (CSV) program provides pediatric surgeons an effective vehicle with which to engage the value agenda, evaluating and improving care over the care continuum in order to improve the function of children's hospitals as larger integrated units.
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Affiliation(s)
| | - Charles G Macias
- University Hospitals Cleveland Medical Center/ Rainbow Babies and Children's Hospital, Cleveland, OH, USA
| | | | - Mary E Fallat
- University of Louisville School of Medicine/ Norton Children's Hospital, Louisville, KY, USA
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Culbert MH, Nelson A, Obaid O, Castanon L, Hosseinpour H, Anand T, El-Qawaqzeh K, Stewart C, Reina R, Joseph B. Failure-to-rescue and mortality after emergent pediatric trauma laparotomy: How are the children doing? J Pediatr Surg 2023; 58:537-544. [PMID: 36150930 DOI: 10.1016/j.jpedsurg.2022.08.017] [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: 01/22/2022] [Revised: 08/12/2022] [Accepted: 08/22/2022] [Indexed: 10/15/2022]
Abstract
INTRODUCTION Emergent trauma laparotomy is associated with mortality rates of up to 40%. There is a paucity of data on the outcomes of emergent trauma laparotomies performed in the pediatric population. The aim of our study was to describe the outcomes, including mortality and FTR, among pediatric trauma patients undergoing emergent laparotomy and identify factors associated with failure-to-rescue (FTR). METHODS We performed a one-year (2017) retrospective cohort analysis of the American College of Surgeons Trauma Quality Improvement Program dataset. All pediatric trauma patients (age <18 years) who underwent emergent laparotomy (laparotomy performed within 2 h of admission) were included. Outcome measures were major in-hospital complications, overall mortality, and failure-to-rescue (death after in-hospital major complication). Multivariate regression analysis was performed to identify factors independently associated with failure-to-rescue. RESULTS Among 120,553 pediatric trauma patients, 462 underwent emergent laparotomy. Mean age was 14±4 years, 76% of patients were male, 49% were White, and 50% had a penetrating mechanism of injury. Median ISS was 25 [13-36], Abdomen AIS was 3 [2-4], Chest AIS was 2 [1-3], and Head AIS was 2 [0-5]. The median time in ED was 33 [18-69] minutes, and median time to surgery was 49 [33-77] minutes. The most common operative procedures performed were splenectomy (26%), hepatorrhaphy (17%), enterectomy (14%), gastrorrhaphy (14%), and diaphragmatic repair (14%). Only 22% of patients were treated at an ACS Pediatric Level I trauma center. The most common major in-hospital complications were cardiac (9%), followed by infectious (7%) and respiratory (5%). Overall mortality was 21%, and mortality among those presenting with hypotension was 31%. Among those who developed in-hospital major complications, the failure-to-rescue rate was 31%. On multivariate analysis, age younger than 8 years, concomitant severe head injury, and receiving packed red blood cell transfusion within the first 24 h were independently associated with failure-to-rescue. CONCLUSIONS Our results show that emergent trauma laparotomies performed in the pediatric population are associated with high morbidity, mortality, and failure-to-rescue rates. Quality improvement programs may use our findings to improve patient outcomes, by increasing focus on avoiding hospital complications, and further refinement of resuscitation protocols. LEVEL OF EVIDENCE Level IV STUDY TYPE: Epidemiologic.
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Affiliation(s)
- Michael Hunter Culbert
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ, United States
| | - Adam Nelson
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ, United States
| | - Omar Obaid
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ, United States
| | - Lourdes Castanon
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ, United States
| | - Hamidreza Hosseinpour
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ, United States
| | - Tanya Anand
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ, United States
| | - Khaled El-Qawaqzeh
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ, United States
| | - Collin Stewart
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ, United States
| | - Raul Reina
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ, United States
| | - Bellal Joseph
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ, United States.
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Abstract
OBJECTIVE To describe the frequency and patterns of postoperative complications and FTR after inpatient pediatric surgical procedures and to evaluate the association between number of complications and FTR. SUMMARY AND BACKGROUND FTR, or a postoperative death after a complication, is currently a nationally endorsed quality measure for adults. Although it is a contributing factor to variation in mortality, relatively little is known about FTR after pediatric surgery. METHODS Cohort study of 200,554 patients within the National Surgical Quality Improvement Program-Pediatric database (2012-2016) who underwent a high (≥ 1%) or low (< 1%) mortality risk inpatient surgical procedures. Patients were stratified based on number of postoperative complications (0, 1, 2, or ≥3) and further categorized as having undergone either a low- or high-risk procedure. The association between the number of postoperative complications and FTR was evaluated with multivariable logistic regression. RESULTS Among patients who underwent a low- (89.4%) or high-risk (10.6%) procedures, 14.0% and 12.5% had at least 1 postoperative complication, respectively. FTR rates after low- and high-risk procedures demonstrated step-wise increases as the number of complications accrued (eg, low-risk- 9.2% in patients with ≥3 complications; high-risk-36.9% in patients with ≥ 3 complications). Relative to patients who had no complications, there was a dose-response relationship between mortality and the number of complications after low-risk [1 complication - odds ratio (OR) 3.34 (95% CI 2.62-4.27); 2 - OR 10.15 (95% CI 7.40-13.92); ≥3-27.48 (95% CI 19.06-39.62)] and high-risk operations [1 - OR 3.29 (2.61-4.16); 2-7.24 (5.14-10.19); ≥3-20.73 (12.62-34.04)]. CONCLUSIONS There is a dose-response relationship between the number of postoperative complications after inpatient surgery and FTR, ever after common, "minor" surgical procedures. These findings suggest FTR may be a potential quality measure for pediatric surgical care.
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