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Tian Y, Allen LD, Ingram MCE, Raval MV. Disparities in Delivery of Ambulatory Surgical Care for Children. JAMA Netw Open 2023; 6:e2317018. [PMID: 37273209 DOI: 10.1001/jamanetworkopen.2023.17018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/06/2023] Open
Affiliation(s)
- Yao Tian
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Lindsay D Allen
- Department of Emergency Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Martha-Conley E Ingram
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Mehul V Raval
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
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Reiter AJ, Sullivan GA, Hu A, Tian Y, Ingram MCE, Balbale SN, Johnson JK, Schäfer W, Holl JL, Raval MV. Pediatric Patient and Caregiver Agreement on Perioperative Expectations and Self-Reported Outcomes. J Surg Res 2023; 282:47-52. [PMID: 36252362 PMCID: PMC10232682 DOI: 10.1016/j.jss.2022.09.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 08/25/2022] [Accepted: 09/20/2022] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Alignment between pediatric patients and caregiver perspectives on patient-reported outcome (PRO) data is contingent upon context. We aimed to assess agreement between patient and caregiver responses to a series of perioperative domains. METHODS Agreement between pediatric patients and caregiver responses to preoperative and postoperative surveys about surgery preparedness, perioperative expectations, PRO Measurement Information System (PROMIS) measures for overall health and pain, and reaching milestones gathered as part of an ongoing clinical trial for children undergoing gastrointestinal surgery, was evaluated. Gwet's AC and Spearman's correlation coefficients were calculated, as appropriate, to assess agreement. RESULTS Of 209 enrolled patients, 65 (31.1%) dyads completed all three surveys and were included. For the domains of education, expectations, and comprehension, patients and caregivers had good agreement with Gwet AC1 with values of 0.80, 0.61, and 0.64, respectively. For milestones, patients and caregivers had very good agreement (Gwet AC1 of 0.95). Milestones measured whether patients achieved certain goals within a prespecified time, including enteral intake (Gwet AC1 0.91 and 0.92 respectively), transition to oral pain medication (Gwet AC1 0.94), ambulation (Gwet AC1 1.00), and return of bowel function (Gwet AC1 0.97). There was moderate to strong agreement between patients and caregivers on PROMIS pain questions (Spearman's correlation: 0.71 preoperatively and 0.51 postoperatively). On PROMIS global health questions, there was strong agreement (0.69 preoperatively and 0.65 postoperatively). CONCLUSIONS Pediatric patient and caregiver agreement on perioperative survey items ranged from moderate to strong. Caregivers' responses may be acceptable when some patient-level responses are not available.
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Affiliation(s)
- Audra J Reiter
- Surgical Outcomes Quality Improvement Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital, Chicago, Illinois
| | - Gwyneth A Sullivan
- Surgical Outcomes Quality Improvement Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital, Chicago, Illinois
| | - Andrew Hu
- Surgical Outcomes Quality Improvement Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital, Chicago, Illinois
| | - Yao Tian
- Surgical Outcomes Quality Improvement Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Martha-Conley E Ingram
- Surgical Outcomes Quality Improvement Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital, Chicago, Illinois
| | - Salva N Balbale
- Center for Health Services and Outcomes Research, Institute of Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Julie K Johnson
- Surgical Outcomes Quality Improvement Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Willemijn Schäfer
- Surgical Outcomes Quality Improvement Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Jane L Holl
- Biological Sciences Division, University of Chicago, Chicago, Illinois
| | - Mehul V Raval
- Surgical Outcomes Quality Improvement Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital, Chicago, Illinois.
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Reiter AJ, Ingram MCE, Raval MV, Garcia E, Hill M, Aranda A, Chandler NM, Gonzalez R, Born K, Mack S, Lamoshi A, Lipskar AM, Han XY, Fialkowski E, Spencer B, Kulaylat AN, Barde A, Shah AN, Adoumie M, Gross E, Mehl SC, Lopez ME, Polcz V, Mustafa MM, Gander JW, Sullivan TM, Sulkowski JP, Ghani O, Huang EY, Rothstein D, Muenks EP, St. Peter SD, Fisher JC, Levy-Lambert D, Reichl A, Ignacio RC, Slater BJ, Tsao K, Berman L. Postoperative respiratory complications in SARS-CoV-2 positive pediatric patients across 20 United States hospitals: A Cohort Study. J Pediatr Surg 2022:S0022-3468(22)00716-3. [PMID: 36428183 PMCID: PMC9632239 DOI: 10.1016/j.jpedsurg.2022.10.048] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 10/20/2022] [Accepted: 10/25/2022] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Data examining rates of postoperative complications among SARS-CoV-2 positive children are limited. The purpose of this study was to evaluate the impact of symptomatic and asymptomatic SARS-CoV-2 positive status on postoperative respiratory outcomes for children. METHODS This retrospective cohort study included SARS-CoV-2 positive pediatric patients across 20 hospitals who underwent general anesthesia from March to October 2020. The primary outcome was frequency of postoperative respiratory complications, including: high-flow nasal cannula/non invasive ventilation, reintubation, pneumonia, Extracorporeal Membrane Oxygenation (ECMO), and 30-day respiratory-related readmissions or emergency department (ED) visits. Univariate analyses were used to evaluate associations between patient and procedure characteristics and stratified analyses by symptoms were performed examining incidence of complications. RESULTS Of 266 SARS-CoV-2 positive patients, 163 (61.7%) were male, and the median age was 10 years (interquartile range 4-14). The majority of procedures were emergent or urgent (n = 214, 80.5%). The most common procedures were appendectomies (n = 78, 29.3%) and fracture repairs (n = 40,15.0%). 13 patients (4.9%) had preoperative symptoms including cough or dyspnea. 26 patients (9.8%) had postoperative respiratory complications, including 15 requiring high-flow oxygen, 8 with pneumonia, 4 requiring non invasive ventilation, 3 respiratory ED visits, and 2 respiratory readmissions. Respiratory complications were more common among symptomatic patients than asymptomatic patients (30.8% vs. 8.7%, p = 0.01). Higher ASA class and comorbidities were also associated with postoperative respiratory complications. CONCLUSIONS Postoperative respiratory complications are less common in asymptomatic versus symptomatic SARS-COV-2 positive children. Relaxation of COVID-19-related restrictions for time-sensitive, non urgent procedures in selected asymptomatic patients may be reasonably considered. Additionally, further research is needed to evaluate the costs and benefits of routine testing for asymptomatic patients. LEVEL OF EVIDENCE Iii, Respiratory complications.
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Affiliation(s)
- Audra J. Reiter
- Division of Pediatric Surgery, Department of Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Surgical Outcomes and Quality Improvement Center, Northwestern University Feinberg School of Medicine, 633N. St. Clair St., 20th floor, Chicago, IL 60611, United States,Corresponding author
| | - Martha-Conley E. Ingram
- Division of Pediatric Surgery, Department of Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Surgical Outcomes and Quality Improvement Center, Northwestern University Feinberg School of Medicine, 633N. St. Clair St., 20th floor, Chicago, IL 60611, United States
| | - Mehul V. Raval
- Division of Pediatric Surgery, Department of Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Surgical Outcomes and Quality Improvement Center, Northwestern University Feinberg School of Medicine, 633N. St. Clair St., 20th floor, Chicago, IL 60611, United States
| | - Elisa Garcia
- Division of Pediatric Surgery, Department of Surgery, McGovern Medical School at University of Texas Health Science Center at Houston, Children's Memorial Hermann Hospital, Houston TX, United States
| | - Madelyn Hill
- Division of Pediatric Surgery, Dayton Children's Hospital, Wright State University, Dayton, OH, United States
| | - Arturo Aranda
- Division of Pediatric Surgery, Dayton Children's Hospital, Wright State University, Dayton, OH, United States
| | - Nicole M Chandler
- Division of Pediatric Surgery, Department of Surgery, John's Hopkins All Children's Hospital, St. Petersburg, FL, United States
| | - Raquel Gonzalez
- Division of Pediatric Surgery, Department of Surgery, John's Hopkins All Children's Hospital, St. Petersburg, FL, United States
| | - Kristen Born
- Division of Pediatric Surgery, Department of Surgery, Nemours Children's Hospital - Delaware, Wilmington DE, United States
| | - Shale Mack
- Division of Pediatric Surgery, Department of Surgery, Nemours Children's Hospital - Delaware, Wilmington DE, United States
| | - Abdulraouf Lamoshi
- Department of Pediatric Surgery, Cohen Children's Medical Center, Northwell Health, New Hyde Park, NY, United States
| | - Aaron M. Lipskar
- Department of Pediatric Surgery, Cohen Children's Medical Center, Northwell Health, New Hyde Park, NY, United States
| | - Xiao-Yue Han
- Division of Pediatric Surgery, Department of Surgery, OHSU School of Medicine, Doernbecher Children's Hospital, Portland, OR, United States
| | - Elizabeth Fialkowski
- Division of Pediatric Surgery, Department of Surgery, OHSU School of Medicine, Doernbecher Children's Hospital, Portland, OR, United States
| | - Brianna Spencer
- Division of Pediatric Surgery, Department of Surgery, Penn State Children's Hospital, Hershey, PA, United States
| | - Afif N. Kulaylat
- Division of Pediatric Surgery, Department of Surgery, Penn State Children's Hospital, Hershey, PA, United States
| | - Amrene Barde
- Division of Pediatric Surgery, Department of Surgery, Rush University, Chicago, IL, United States
| | - Ami N. Shah
- Division of Pediatric Surgery, Department of Surgery, Rush University, Chicago, IL, United States
| | - Maeva Adoumie
- Division of Pediatric Surgery, Department of Surgery, Stony Brook Children's Hospital, Stony Brook, NY, United States
| | - Erica Gross
- Division of Pediatric Surgery, Department of Surgery, Stony Brook Children's Hospital, Stony Brook, NY, United States
| | - Steven C. Mehl
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston TX, United States
| | - Monica E. Lopez
- Department of Pediatric Surgery, Vanderbilt University Medical Center, Monroe Carell Jr. Children's Hospital, Nashville TN, United States
| | - Valerie Polcz
- Division of Pediatric Surgery, Department of Surgery, UF Health, University of Florida, Gainesville, FL, United States
| | - Moiz M. Mustafa
- Division of Pediatric Surgery, Department of Surgery, UF Health, University of Florida, Gainesville, FL, United States
| | - Jeffrey W. Gander
- Division of Pediatric Surgery, Department of Surgery, UVA Children's Hospital, Charlottesville, VA, United States
| | - Travis M. Sullivan
- Division of Pediatric Surgery, Department of Surgery, Children's Hospital of Richmond at VCU, Richmond VA, United States
| | - Jason P. Sulkowski
- Division of Pediatric Surgery, Department of Surgery, Children's Hospital of Richmond at VCU, Richmond VA, United States
| | - Owais Ghani
- Department of Pediatric Surgery, Vanderbilt University Medical Center, Monroe Carell Jr. Children's Hospital, Nashville TN, United States
| | - Eunice Y. Huang
- Department of Pediatric Surgery, Vanderbilt University Medical Center, Monroe Carell Jr. Children's Hospital, Nashville TN, United States
| | - David Rothstein
- Division of Pediatric Surgery, Department of Surgery, Seattle Children's Hospital, Seattle WA, United States
| | - E. Peter Muenks
- Division of Pediatric Surgery, Department of Surgery, Children's Mercy Kansas City, Kansas City MO, United States
| | - Shawn D. St. Peter
- Division of Pediatric Surgery, Department of Surgery, Children's Mercy Kansas City, Kansas City MO, United States
| | - Jason C. Fisher
- Division of Pediatric Surgery, Department of Surgery, Hassenfeld Children's Hospital at NYU Langone, New York City, NY, United States
| | - Dina Levy-Lambert
- Division of Pediatric Surgery, Department of Surgery, Hassenfeld Children's Hospital at NYU Langone, New York City, NY, United States
| | - Allison Reichl
- Division of Pediatric Surgery, Department of Surgery, Rady Children's Hospital, University of California San Diego School of Medicine, San Diego, CA, United States
| | - Romeo C. Ignacio
- Division of Pediatric Surgery, Department of Surgery, Rady Children's Hospital, University of California San Diego School of Medicine, San Diego, CA, United States
| | - Bethany J. Slater
- Division of Pediatric Surgery, Department of Surgery, Comer Children's Hospital, University of Chicago, Chicago, IL, United States
| | - KuoJen Tsao
- Division of Pediatric Surgery, Department of Surgery, McGovern Medical School at University of Texas Health Science Center at Houston, Children's Memorial Hermann Hospital, Houston TX, United States
| | - Loren Berman
- Division of Pediatric Surgery, Department of Surgery, Nemours Children's Hospital - Delaware, Wilmington DE, United States
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Ingram MCE, Tian Y, Kennedy S, Schäfer WLA, Johnson JK, Apley DW, Mehrotra S, Holl JL, Raval MV. Pilot implementation of opioid stewardship measures using the national surgical quality improvement program-pediatric platform. J Pediatr Surg 2022; 57:130-136. [PMID: 34996606 PMCID: PMC9203599 DOI: 10.1016/j.jpedsurg.2021.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 11/22/2021] [Accepted: 12/10/2021] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Data surrounding optimal pediatric postoperative opioid prescribing are incomplete. The objective of this study was to leverage the American College of Surgeons (ACS) National Surgical Quality Improvement Program-Pediatric (NSQIP-P) and assess feasibility of added data collection surrounding pediatric perioperative pain management practices including opioid prescribing at discharge. METHODS Nineteen (19) novel data elements were added to NSQIP-P data collection of selected patients, ages 5-18 years, who had undergone surgery at a single, free-standing children's hospital. Metrics around data abstraction and completion of variables were collected. Univariate analyses (using Chi-square or Wilcoxon Rank Sum tests) and multiple logistic regressions were performed to describe predictors of opioid prescribing at discharge and to monitor adherence to Food and Drug Administration (FDA) prescribing recommendations. RESULTS Median abstraction time of the novel variables decreased from 12 to 5 min per patient over 13 months with 94% variable completion rate. Of 878 patients, 302 (36.4%) were prescribed opioids at discharge. Factors associated with an opioid prescription included older age (p < 0.001), white race (p < 0.05), undergoing an orthopedic surgery (p < 0.001), and receiving a regional block perioperatively (p < 0.001). All opioid prescriptions met FDA guidelines with no patients receiving codeine, and 98% of patients receiving opioid prescriptions < 50 morphine milli-equivalents per day. CONCLUSION Collecting data on current pain management practices, opioid prescribing, and adherence to safety recommendations is feasible using the NSQIP-P with little added burden. Further expansion of data collection is needed to develop generalizable optimal prescribing practices for post-discharge pain management for children.
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Affiliation(s)
- Martha-Conley E Ingram
- Feinberg School of Medicine, Department Of Surgery, Division of Pediatric Surgery, Northwestern University, Chicago, IL, USA.
| | - Yao Tian
- Feinberg School of Medicine, Department Of Surgery, Division of Pediatric Surgery, Northwestern University, Chicago, IL, USA
| | - Sarah Kennedy
- American College of Surgeons, National Surgical Quality Improvement Program Pediatric (NSQIP-Peds), Ann And Robert H Lurie Children's Hospital Of Chicago, Chicago, IL, USA
| | - Willemijn L A Schäfer
- Feinberg School of Medicine, Department Of Surgery, Division of Pediatric Surgery, Northwestern University, Chicago, IL, USA
| | - Julie K Johnson
- Feinberg School of Medicine, Department Of Surgery, Division of Pediatric Surgery, Northwestern University, Chicago, IL, USA
| | - Daniel W Apley
- Department Of Engineering, Northwestern University, Chicago, IL, USA
| | - Sanjay Mehrotra
- Department Of Engineering, Northwestern University, Chicago, IL, USA
| | - Jane L Holl
- Center for Healthcare Delivery, Science, and Innovation, University of Chicago Medicine, Chicago, IL, USA
| | - Mehul V Raval
- Feinberg School of Medicine, Department Of Surgery, Division of Pediatric Surgery, Northwestern University, Chicago, IL, USA
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Olson SL, Ingram MCE, Graffy PM, Murphy PM, Tian Y, Samis JH, Josefson JL, Rastatter JC, Raval MV. Effect of surgeon volume on pediatric thyroid surgery outcomes: A systematic review. J Pediatr Surg 2022; 57:208-215. [PMID: 34980469 DOI: 10.1016/j.jpedsurg.2021.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 11/26/2021] [Accepted: 12/01/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Pediatric thyroidectomy has been identified as a surgical procedure that may benefit from concentrating cases to high-volume surgeons. This systematic review aimed to address the definition of "high-volume surgeon" for pediatric thyroidectomy and to examine the relationship between surgeon volume and outcomes. METHODS PubMed, Embase, Cochrane Library, Scopus, Web of Science, ClinicalTrials.gov, and OpenGrey databases were searched for through February 2020 for studies which reported on pediatric thyroidectomy and specified surgeon volume and surgical outcomes. RESULTS Ten studies, encompassing 6430 patients, were included in the review. Five single-center retrospective studies reported only on high-volume surgeons, one single center retrospective study reported on only low-volume surgeons, and four national database studies (2 cross sectional, 2 retrospective reviews) reported outcomes for both high-volume and low-volume surgeons. Majority of patients underwent total thyroidectomy (54.9%); common indications for surgery were malignancy (41.7%) and hyperthyroidism/thyroiditis (40.5%). Rates of transient hypocalcemia (11.4% - 74.2%), transient recurrent laryngeal nerve injury (0% - 9.7%), and bleeding (0.5% - 4.3%) varied across studies. Definitions for high-volume pediatric thyroid surgeons ranged from ≥9 annual pediatric thyroid operations to >200 annual thyroid operations (with >30 pediatric cases). Four studies reported significantly better outcomes, including lower post-operative complications and shorter length of hospital stay, for patients treated by high-volume surgeons. CONCLUSIONS Despite significant variation in caseloads to define volume, pediatric thyroid patients have generally better outcomes when operated on by higher volume surgeons. Concentration thyroidectomy cases to a smaller cohort of surgeons within pediatric practices may confer improved outcomes. LEVEL OF EVIDENCE Systematic Reviews and Meta-Analyses; Level IV.
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Affiliation(s)
- Sydney L Olson
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Martha-Conley E Ingram
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Peter M Graffy
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Peggy M Murphy
- Pritzker Research Library, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Yao Tian
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Jill H Samis
- Division of Pediatric Endocrinology, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Jami L Josefson
- Division of Pediatric Endocrinology, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Jeffery C Rastatter
- Department of Otorhinolaryngology-Head & Neck Surgery, Northwestern University, Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Mehul V Raval
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States.
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Ingram MCE, Nagalla M, Shan Y, Nasca BJ, Thomas AC, Reddy S, Bilimoria KY, Stey A. Sex-Based Disparities in Timeliness of Trauma Care and Discharge Disposition. JAMA Surg 2022; 157:609-616. [PMID: 35583876 DOI: 10.1001/jamasurg.2022.1550] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Differences in time to diagnostic and therapeutic measures can contribute to disparities in outcomes. However, whether there is an association of timeliness by sex for trauma patients is unknown. Objective To investigate whether sex-based differences in time to definitive interventions exist for trauma patients in the US and whether these differences are associated with outcomes. Design, Setting, and Participants This was a retrospective cohort study conducted from July 2020 to July 2021, using the 2013 to 2016 Trauma Quality Improvement Program (TQIP) databases from level I to III trauma centers in the US. Patients 18 years or older with an Injury Severity Score (ISS) greater than 15 and who carried diagnoses of traumatic brain injury, intra-abdominal injury, pelvic fracture, femur fracture, and spinal injury as a result of their trauma were included in the study. Data were analyzed from July 2020 to July 2021. Main Outcomes and Measures Primary outcomes assessed timeliness to interventions, using Wilcoxon signed rank and χ2 tests. Secondary outcomes included location of discharge after injury, using propensity score-matched generalized estimating equations modeling. Results Of the 28 332 patients included, 20 002 (70.6%) were male patients (mean [SD] age, 43.3 [18.2] years) and 8330 (29.4%) were female patients (mean [SD] age, 48.5 [21.1] years), with significantly different distributions of ISS scores (ISS score 16-24: male patient, 10 622 [53.1%]; female patient, 4684 [56.2%]; ISS score 41-74: male patient, 2052 [10.3%]; female patient, 852 [10.2%]). Male patients more frequently had abdominal (4257 [21.3%] vs 1268 [15.2%]) and spinal cord (3989 [20.0%] vs 1274 [15.3%]) injuries, whereas female patients experienced greater proportions of femur (3670 [44.0%] vs 8422 [42.1%]) and pelvic (3970 [47.6%] vs 6963 [34.8%]) fractures. Female patients experienced significantly longer emergency department length of stay (median [IQR], 184 [92-314] minutes vs 172 [86-289] minutes; P < .001), longer time in pretriage (median [IQR], 52 [36-80] minutes vs 49 [34-77] minutes; P < .001), and increased likelihood of discharge to nursing or long-term care facilities instead of home after matching by age, ISS, mechanism, and injury type (male patient:female patient, odds ratio, 0.72; 95% CI, 0.67-0.78). Conclusions and Relevance Results of this cohort study suggest that female trauma patients experienced slightly longer delays in trauma care and had a higher likelihood of discharge to long-term care facilities than their male counterparts.
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Affiliation(s)
- Martha-Conley E Ingram
- Surgical Outcomes Quality Improvement Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Monica Nagalla
- Surgical Outcomes Quality Improvement Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Ying Shan
- Surgical Outcomes Quality Improvement Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Brian J Nasca
- Surgical Outcomes Quality Improvement Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Arielle C Thomas
- Committee on Trauma, American College of Surgeons, Chicago, Illinois
| | - Susheel Reddy
- Surgical Outcomes Quality Improvement Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Karl Y Bilimoria
- Surgical Outcomes Quality Improvement Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Anne Stey
- Surgical Outcomes Quality Improvement Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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Skertich NJ, Ingram MCE, Sullivan GA, Grunvald M, Ritz E, Shah AN, Raval MV. Postoperative complications in pediatric patients with cerebral palsy. J Pediatr Surg 2022; 57:424-429. [PMID: 34218929 DOI: 10.1016/j.jpedsurg.2021.05.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 05/17/2021] [Accepted: 05/31/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND/PURPOSE To assess surgical outcomes of patients with cerebral palsy (CP) and if they differ from patients without CP. METHODS The NSQIP-Pediatric database from 2012 to 2019 was used to compare differences in presenting characteristics and outcomes between patients with and without CP. Chi-square tests and multivariable logistic regression analysis were used to determine significance. RESULTS 119,712 patients, 433 (0.4%) with CP, 119,279 (99.6%) without, were identified. Patients with CP had more postoperative complications (19.4% vs. 6.9%, p < 0.001) with an OR of 3.2, (95%CI 2.5-4.1, p < 0.001) on univariable analysis. They underwent fewer laparoscopic procedures (79.1% vs. 90.8%, p < 0.001), had more readmissions (10.2% vs. 3.8%, p < 0.001), reoperations (5.1% vs. 1.2%, p < 0.001), and longer length of stays (LOS) (median 3 versus 1 day, p < 0.001). On multivariable analysis, having CP did not increase the odds of postoperative morbidity (OR 0.99, 95% CI 0.7-1.3), but higher ASA class, congenital lung malformation, gastrointestinal disease, coagulopathy, preoperative inotropic support, oxygen use, nutritional support, and steroid use significantly increase the odds of morbidity, all of which were more common in patients with CP. CONCLUSION Patients with CP have more postoperative complications, open procedures, and longer LOS. Patient complexity may account for these differences and risk-directed perioperative planning may improve outcomes. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Nicholas J Skertich
- Division of Pediatric Surgery, Department of Surgery, Rush University Medical Center, Chicago, IL, 60612, United States.
| | - Martha-Conley E Ingram
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, 60611, United States
| | - Gwyneth A Sullivan
- Division of Pediatric Surgery, Department of Surgery, Rush University Medical Center, Chicago, IL, 60612, United States
| | - Miles Grunvald
- Division of Pediatric Surgery, Department of Surgery, Rush University Medical Center, Chicago, IL, 60612, United States
| | - Ethan Ritz
- Rush Bioinformatics and Biostatistics Core, Rush University Medical Center, Chicago, IL 60612, United States
| | - Ami N Shah
- Division of Pediatric Surgery, Department of Surgery, Rush University Medical Center, Chicago, IL, 60612, United States
| | - Mehul V Raval
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, 60611, United States.
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Olson SL, Ingram MCE, Samis JH, Josefson JL, Rastatter JC, Rothstein DH, Danko M, Moriarty KP, Rich B, Raval MV. Surgeon Perceptions of Volume Threshold and Essential Practices for Pediatric Thyroidectomy. J Am Coll Surg 2021. [DOI: 10.1016/j.jamcollsurg.2021.08.409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Tian Y, Hall M, Ingram MCE, Hu A, Raval MV. Trends and Variation in the Use of Observation Stays at Children's Hospitals. J Hosp Med 2021; 16:645-651. [PMID: 34328847 DOI: 10.12788/jhm.3622] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 03/22/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Observation status could improve efficiency of healthcare resource use but also might shift financial burdens to patients and hospitals. Although the use of observation stays has increased for adult patient populations, the trends are unknown among hospitalized children. OBJECTIVE The goal of this study was to describe recent trends in observation stays for pediatric populations at children's hospitals. DESIGN, SETTING, AND PARTICIPANTS Both observation and inpatient stays for all conditions were retrospectively studied using the Pediatric Health Information System database (2010 to 2019). EXPOSURE, MAIN OUTCOMES, AND MEASURES Patient type was classified as inpatient or observation status. Main outcomes included annual percentage of observation stays, annual percentage of observation stays having prolonged length of stay (>2 days), and growth rates of observation stays for the 20 most common conditions. Risk adjusted hospital-level use of observation stays was estimated using generalized linear mixed-effects models. RESULTS The percentage of observation stays increased from 23.6% in 2010 to 34.3% in 2019 (P < .001), and the percentage of observation stays with prolonged length of stay rose from 1.1% to 4.6% (P < .001). Observation status was expanded among a diverse group of clinical conditions; diabetes mellitus and surgical procedures showed the highest growth rates. Adjusted hospital-level use ranged from 0% to 67% in 2019, indicating considerable variation among hospitals. CONCLUSION Based on the increase in observation stays, future studies should explore the appropriateness of observation care related to efficient use of healthcare resources and financial implications for hospitals and patients.
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Affiliation(s)
- Yao Tian
- Surgical Outcomes Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Matt Hall
- Children's Hospital Association, Lenexa, Kansas
| | - Martha-Conley E Ingram
- Surgical Outcomes Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann and Robert H Lurie Children's Hospital, Chicago, Illinois
| | - Andrew Hu
- Surgical Outcomes Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann and Robert H Lurie Children's Hospital, Chicago, Illinois
| | - Mehul V Raval
- Surgical Outcomes Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann and Robert H Lurie Children's Hospital, Chicago, Illinois
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10
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Ingram MCE, Studer A, Schechter J, Martin SA, Patel M, Roben ECZ, Burjek NE, Birmingham PK, Raval MV. Implementing PDSA Methodology for Pediatric Appendicitis Increases Care Value for a Tertiary Children's Hospital. Pediatr Qual Saf 2021; 6:e442. [PMID: 34345755 PMCID: PMC8322485 DOI: 10.1097/pq9.0000000000000442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 02/08/2021] [Indexed: 11/25/2022] Open
Abstract
Supplemental Digital Content is available in the text. Introduction: We used the plan-do-study-act (PDSA) framework to develop and implement an evidence-based clinical practice guideline (CPG) within an urban, tertiary children’s referral center. Methods: We developed an evidence-based CPG for appendicitis using iterative PDSA cycles. Similar CPGs from other centers were reviewed and modified for local implementation. Adjuncts included guideline-specific order sets and operative notes in the electronic medical record system. Outcomes included length of stay (LOS), 30-day readmissions, hospital costs, and patient and family experience (PFE) scores. Our team tracked outcome, process, and balancing measures using Statistical Process Charts. Outcome measures were compared over 2 fiscal quarters preimplementation and 3 fiscal quarters postimplementation, using interrupted time series, student t test, and chi-square tests when appropriate. Results: LOS for simple (uncomplicated) appendicitis decreased to 0.87 days (interquartile range [IQR] 0.87–0.94 days) from 1.1 days (IQR 0.97–1.42 days). LOS for complicated appendicitis decreased to 4.96 days (IQR 4.95–6.15) from 5.58 days (IQR 5.16–6.09). This reduction equated to an average cost-savings of $1,122/patient. Thirty-day readmission rates have remained unchanged. PFE scores increased across all categories and have remained higher than national benchmarks. Conclusion: Development and Implementation of a CPG for pediatric appendicitis using the PDSA framework adds value to care provided within a large tertiary center.
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Affiliation(s)
- Martha-Conley E Ingram
- Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Ill
| | - Abbey Studer
- Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Ill
| | - Jamie Schechter
- Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Ill
| | - Sarah A Martin
- Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Ill
| | - Manisha Patel
- Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Ill
| | - Emily C Z Roben
- Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Ill
| | - Nicholas E Burjek
- Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Ill
| | - Patrick K Birmingham
- Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Ill
| | - Mehul V Raval
- Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Ill
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Tian Y, Ingram MCE, Raval MV. National Trends and Disparities in the Diffusion of Laparoscopic Surgery for Children in the United States. J Laparoendosc Adv Surg Tech A 2021; 31:1061-1066. [PMID: 34152864 DOI: 10.1089/lap.2021.0013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Background: Laparoscopic surgery has become the standard of care for many surgical treatments. The diffusion of laparoscopy has been investigated for adult patient populations but is still unknown for pediatric populations. This study sought to describe national trends in diffusion of laparoscopic surgery for common pediatric conditions and identify disparities in use of laparoscopic surgery. Study Design: A retrospective analysis of serial cross-sectional data was performed using the Healthcare Cost and Utilization Project's Kids' Inpatient Database from 1997 to 2016. Pediatric patients (ages ≤18) undergoing appendectomy, cholecystectomy, fundoplication, or inguinal hernia repair were identified. The diffusion of laparoscopy for each procedure was measured using the proportion of laparoscopic surgeries over years. Results: National trends demonstrate increases in the use of laparoscopy for children over the past two decades from 13.4% to 88.7% for appendectomy, from 82.6% to 94.9% for cholecystectomy, from 7.4% to 77.4% for fundoplication, and from 1.5% to 23.5% for repair of inguinal hernia (P < .001). Disparities in diffusion of laparoscopy were found from various pediatric populations, and the disparities varied by specific procedures and years. In particular, the proportion of laparoscopic appendectomy in 1997 was 11.3% at urban teaching hospitals and was 13.9% at rural hospitals (P = .01), while the proportions in 2016 increased to 90.8% at urban teaching hospitals versus 71.3% at rural hospitals (P < .001). Conclusions: Laparoscopy has become the standard surgical care for common pediatric surgical conditions. Widening disparities in use of laparoscopic surgery for pediatric populations appear between urban teaching hospitals and rural hospitals.
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Affiliation(s)
- Yao Tian
- Surgical Outcomes Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Martha-Conley E Ingram
- Surgical Outcomes Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA.,Division of Pediatric Surgery, Department of Surgery, Feinberg School of Medicine, Northwestern University, Ann & Robert H. Lurie, Children's Hospital, Chicago, Illinois, USA
| | - Mehul V Raval
- Surgical Outcomes Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA.,Division of Pediatric Surgery, Department of Surgery, Feinberg School of Medicine, Northwestern University, Ann & Robert H. Lurie, Children's Hospital, Chicago, Illinois, USA
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Sarkar A, Ingram MCE, Tian Y, Many BT, Rizeq Y, Goldstein SD, Rigsby CK, Raval MV. A Retrospective Cohort Study of Optimal Contrast for Successful Intussusception Reduction: Institutional Practices Matter. J Surg Res 2021; 267:159-166. [PMID: 34147862 DOI: 10.1016/j.jss.2021.05.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 04/20/2021] [Accepted: 05/07/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND The first-line treatment for intussusception is radiologic reduction with either air-contrast enema (AE) or liquid-contrast enema (LE). The purpose of this study was to explore relationships between self-reported institutional AE or LE intussusception reduction preferences and rates of operative intervention and bowel resection. METHODS Pediatric Health Information System (PHIS) hospitals were contacted to assess institutional enema practices for intussusception. A retrospective study using 2009-2018 PHIS data was conducted for patients aged 0-5 y to evaluate outcomes. Chi-squared tests were used to test for differences in the distribution of surgical patients by hospital management approach. RESULTS Of the 45 hospitals, 20 (44%) exclusively used AE, 4 (9%) exclusively used LE, and 21 (46%) used a mixed practice. Of 24,688 patients identified from PHIS, 13,231 (54%) were at exclusive AE/LE hospitals and 11,457 (46%) were at mixed practice hospitals. Patients at AE/LE hospitals underwent operative procedures at lower rates than at mixed practice hospitals (14.8% versus 16.5%, P< 0.001) and were more likely to undergo bowel resection (31.1% versus 27.1%, P= 0.02). CONCLUSIONS Practice variation exists in hospital-level approaches to radiologic reduction of intussusception and mixed practices may impact outcomes.
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Affiliation(s)
- Arjun Sarkar
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Martha-Conley E Ingram
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Yao Tian
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Benjamin T Many
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Yazan Rizeq
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Seth D Goldstein
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Cynthia K Rigsby
- Department of Medical Imaging, Department of Radiology, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Mehul V Raval
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.
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Tian Y, Ingram MCE, Hall M, Raval MV. ICD-10 Transition Influences Trends in Perforated Appendix Admission Rate. J Surg Res 2021; 266:345-351. [PMID: 34077864 DOI: 10.1016/j.jss.2021.04.028] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 03/27/2021] [Accepted: 04/16/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND This study sought to evaluate the influence of International Classification of Diseases, Tenth Revision (ICD-10) transition on Perforated Appendix Admission Rate (PAAR), which is a commonly used indicator representing access to care developed by Agency for Healthcare Research and Quality (AHRQ). MATERIALS AND METHODS In this interrupted time series study of Pediatric Health Information System database from 2013 to 2018, we employed three study phases (pre-implementation, washout, and initial implementation) to evaluate the influence of ICD-10 transition on trends in PAAR. ICD-10 diagnosis codes suggested by AHRQ's specifications were used to identify perforated and simple appendicitis, and PAAR was estimated accordingly. Generalized linear mixed models were used to examine the association of ICD-10 initial implementation and being documented as perforated appendicitis on encounter level. RESULTS We identified a total of 94,810 encounters diagnosed with appendicitis, and almost all patients' characteristics were similar over the three study phases, except for PAAR. The pre-implementation PAAR in October 2013 was 33.1%, and the immediate influence of ICD-10 transition on PAAR was 3.2% (P = 0.002), with a 0.38% per quarter increase over time (P = 0.02). After adjusting for age, gender, race/ethnicity, payer, and year, the likelihood of being documented as having perforated appendicitis in 2016 was 1.5 times higher than the estimated likelihood before the implementation (adjusted Odds Ratio: 1.51; 95% Confidence Interval: 1.40-1.63; P < 0.001). CONCLUSIONS The 2015-2018 ICD-10 transition may be erroneously associated with an increasing trend of PAAR. Care should be taken when interpreting the metric during this period.
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Affiliation(s)
- Yao Tian
- Surgical Outcomes Quality Improvement Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois 60611
| | - Martha-Conley E Ingram
- Surgical Outcomes Quality Improvement Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois 60611; Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital, Chicago, Illinois 60611
| | - Matt Hall
- Children's Hospital Association, Lenexa, Kansas
| | - Mehul V Raval
- Surgical Outcomes Quality Improvement Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois 60611; Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital, Chicago, Illinois 60611.
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Ingram MCE, Mehl S, Rentea RM, Lopez ME, Raval MV, Newton C, Berman L. Sharing strategies for safe delivery of surgical care for children in the COVID-19 Era. J Pediatr Surg 2021; 56:196-198. [PMID: 33248680 PMCID: PMC7661910 DOI: 10.1016/j.jpedsurg.2020.11.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 11/10/2020] [Indexed: 12/20/2022]
Affiliation(s)
- Martha-Conley E. Ingram
- 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, USA,Corresponding author
| | - Steven Mehl
- Division of Pediatric Surgery, Department of Surgery, Baylor College of Medicine, Texas Children's Hospital, Houston TX, USA
| | - Rebecca M. Rentea
- Division of Pediatric Surgery, Department of Surgery, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
| | - Monica E. Lopez
- Division of Pediatric Surgery, Department of Surgery, Baylor College of Medicine, Texas Children's Hospital, Houston TX, USA
| | - Mehul V. Raval
- 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, USA
| | - Christopher Newton
- Division of Pediatric Surgery, Department of Surgery, UCSF East Bay, Oakland, CA, USA
| | - Loren Berman
- Division of Pediatric Surgery, Department of Surgery, Sidney Kimmel Medical College at Thomas Jefferson University Hospital, Nemours Al duPont Hospital for Children, Wilmington, DE, USA
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15
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Tian Y, Ingram MCE, Raval MV. A pitfall of using general equivalence mappings to estimate national trends of surgical utilization for pediatric patients. J Pediatr Surg 2020; 55:2602-2607. [PMID: 32278543 DOI: 10.1016/j.jpedsurg.2020.03.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Revised: 02/27/2020] [Accepted: 03/08/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND General equivalence mappings (GEMs) were developed to facilitate a transition from International Classification of Diseases, Ninth Revision (ICD-9) to ICD, Tenth Revision (ICD-10). Validation of GEMs is suggested as coding errors have been reported for adult populations. The purpose of this study was to illustrate limitations of the GEMs for pediatric surgical procedures. METHODS Using the 2014 to 2016 National Inpatient Sample, we evaluated all patients undergoing inguinal hernia repair. ICD-9 codes for the repair were independently classified as laparoscopic or open approach by two surgeons. Conversions of the ICD-9 to ICD-10 codes were compared between the GEMs strategy and surgeons' manual mapping. National trends were compared for overall, adult, and pediatric populations. RESULTS We found significant inconsistencies in the proportion of laparoscopic inguinal hernia repair based on mapping strategies employed. For adults, the comparison of the proportions in 2016 was 17.79% (GEMs) versus 21.44% (Manual). In pediatric population, the contrast was 0.45% (GEMs) versus 17.75% (Manual), and no laparoscopic repair cases were found using GEMs in the last quarter of 2015. CONCLUSION Some conversions of ICD-9 and ICD-10 using the current GEMs are not valid for certain populations and procedures. Clinical validation of coding conversions is essential. LEVEL OF EVIDENCE Level V.
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Affiliation(s)
- Yao Tian
- Surgical Outcomes Quality Improvement Center, Northwestern University Feinberg School of Medicine, Chicago, IL 60611
| | - Martha-Conley E Ingram
- Surgical Outcomes Quality Improvement Center, Northwestern University Feinberg School of Medicine, Chicago, IL 60611; Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital, Chicago, IL 60611
| | - Mehul V Raval
- Surgical Outcomes Quality Improvement Center, Northwestern University Feinberg School of Medicine, Chicago, IL 60611; Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital, Chicago, IL 60611.
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Skertich NJ, Ingram MCE, Ritz E, Shah AN, Raval MV. The influence of prematurity on neonatal surgical morbidity and mortality. J Pediatr Surg 2020; 55:2608-2613. [PMID: 32498947 DOI: 10.1016/j.jpedsurg.2020.03.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 03/06/2020] [Accepted: 03/21/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND As survival rates amongst premature infants have improved, prematurity remains a leading contributor to neonatal surgical morbidity and mortality. This study aims to better assess the influence of prematurity on surgical outcomes. METHODS The NSQIP-Pediatric database was used to compare outcomes between preterm and term infants undergoing surgical repair of select congenital anomalies from 2012 to 2017. Prematurity was categorized as extremely preterm (EP) (<29 weeks), very preterm (VP) (29-32 weeks), moderate to late preterm (MLP) (33-36 weeks), and term (≥37 weeks). Significance was determined using Chi-square tests, Fisher exact tests and adjusted logistic regression analysis. RESULTS 4852 infants were identified with 45 (0.9%) EP, 211 (4.3%) VP, 1492 (30.8%) MLP, and 3104 (64.0%) term. Compared to term, preterm infants have increased odds of surgical morbidity (EP Odds Ratio (OR) 3.2 95% Confidence Interval (CI) 1.6-6.4, VP OR 1.2 95%CI 0.9-1.7, and MLP OR 1.2 95%CI 1.0-1.4). 30-day mortality decreased as neonatal age increased from 22.2% EP to 2.9% term (p < 0.001). Premature populations had higher rates of sepsis, pneumonia, bleeding requiring transfusion and 30-day mortality. CONCLUSIONS Prematurity increases morbidity and mortality amongst neonates undergoing surgery. Risk-adjustment for prematurity is needed and premature infants may have unique quality improvement targets. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Nicholas J Skertich
- Division of Pediatric Surgery, Department of Surgery, Rush University Medical Center, Chicago, IL, 60612, USA.
| | - Martha-Conley E Ingram
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, 60611, USA
| | - Ethan Ritz
- Rush Bioinformatics and Biostatistics Core, Rush University Medical Center, Chicago, IL 60612, USA
| | - Ami N Shah
- Division of Pediatric Surgery, Department of Surgery, Rush University Medical Center, Chicago, IL, 60612, USA
| | - Mehul V Raval
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, 60611, USA.
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Raval MV, Wymore E, Ingram MCE, Tian Y, Johnson JK, Holl JL. Assessing effectiveness and implementation of a perioperative enhanced recovery protocol for children undergoing surgery: study protocol for a prospective, stepped-wedge, cluster, randomized, controlled clinical trial. Trials 2020; 21:926. [PMID: 33198767 PMCID: PMC7667817 DOI: 10.1186/s13063-020-04851-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 10/29/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Perioperative enhanced recovery protocols (ERPs) have been found to decrease hospital length of stay, in-hospital costs, and complications among adult surgical populations but evidence for pediatric populations is lacking. The study is designed to evaluate the adoption, effectiveness, and generalizability of a 21-element ERP, adapted for pediatric surgery. METHODS The multicenter study is a stepped-wedge, cluster-randomized, pragmatic clinical trial that will evaluate the effectiveness of the ENhanced Recovery In CHildren Undergoing Surgery (ENRICH-US) intervention while also assessing site-specific adaptations, implementation fidelity, and sustainability. The target patient population is pediatric patients, between 10 and 18 years old, who undergo elective gastrointestinal surgery. Eighteen (N = 18) participating sites will be randomly assigned to one of three clusters with each cluster, in turn, being randomly assigned to an intervention start period (stepped-wedge). Each cluster will participate in a Learning Collaborative, using the National Implementation Research Network's five Active Implementation Frameworks (AIFs) (competency, organization, and leadership), as drivers of facilitation of rapid-cycle adaptations and implementation. The primary study outcome is hospital length of stay, with implementation metrics being used to evaluate adoption, fidelity, and sustainability. Additional clinical outcomes include opioid use, post-surgical complications, and post-discharge healthcare utilization (clinic/emergency room visits, telephone calls to clinic, and re-hospitalizations), as well as, assess patient- and parent-reported health-related quality of life outcomes. The protocol adheres to the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) checklist. DISCUSSION The study provides a unique opportunity to accelerate the adoption of ERPs across 18 US pediatric surgical centers and to evaluate, for the first time, the effect of a pediatric-specific ENRICH-US intervention on clinical and implementation outcomes. The study design and methods can serve as a model for future pediatric surgical quality improvement implementation efforts. TRIAL REGISTRATION ClinicalTrials.gov NCT04060303 . Registered on 07 August 2019.
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Affiliation(s)
- Mehul V Raval
- Surgical Outcomes Quality Improvement Center, Northwestern University Feinberg School of Medicine, 633 N. St. Clair, 20th Floor, Chicago, IL, 60611, USA. .,Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital, 225 E. Chicago Ave, Chicago, IL, 60611, USA.
| | - Erin Wymore
- Surgical Outcomes Quality Improvement Center, Northwestern University Feinberg School of Medicine, 633 N. St. Clair, 20th Floor, Chicago, IL, 60611, USA
| | - Martha-Conley E Ingram
- Surgical Outcomes Quality Improvement Center, Northwestern University Feinberg School of Medicine, 633 N. St. Clair, 20th Floor, Chicago, IL, 60611, USA.,Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital, 225 E. Chicago Ave, Chicago, IL, 60611, USA
| | - Yao Tian
- Surgical Outcomes Quality Improvement Center, Northwestern University Feinberg School of Medicine, 633 N. St. Clair, 20th Floor, Chicago, IL, 60611, USA
| | - Julie K Johnson
- Surgical Outcomes Quality Improvement Center, Northwestern University Feinberg School of Medicine, 633 N. St. Clair, 20th Floor, Chicago, IL, 60611, USA
| | - Jane L Holl
- Biological Science Division, University of Chicago, 5841 S. Maryland Avenue, Chicago, IL, 60637, USA
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Ingram MCE, Raval MV, Newton C, Lopez ME, Berman L. Characterization of initial North American pediatric surgical response to the COVID-19 pandemic. J Pediatr Surg 2020; 55:1431-1435. [PMID: 32561172 PMCID: PMC7280130 DOI: 10.1016/j.jpedsurg.2020.06.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 05/21/2020] [Accepted: 06/03/2020] [Indexed: 12/11/2022]
Abstract
INTRODUCTION The impact of COVID-19 pandemic on pediatric surgical care systems is unknown. We present an initial evaluation of self-reported pediatric surgical policy changes from hospitals across North America. METHODS On March 30, 2020, an online open access, data gathering spreadsheet was made available to pediatric surgeons through the American Pediatric Surgical Association (APSA) website, which captured information surrounding COVID-19 related policy changes. Responses from the first month of the pandemic were collected. Open-ended responses were evaluated and categorized into themes and descriptive statistics were performed to identify areas of consensus. RESULTS Responses from 38 hospitals were evaluated. Policy changes relating to three domains of program structure and care processes were identified: internal structure, clinical workflow, and COVID-19 safety/prevention. Interhospital consensus was high for reducing in-hospital staffing, limiting clinical fellow exposure, implementing telehealth for conducting outpatient clinical visits, and using universal precautions for trauma. Heterogeneity in practices existed for scheduling procedures, implementing testing protocols, and regulating use of personal protective equipment. CONCLUSIONS The COVID-19 pandemic has induced significant upheaval in the usual processes of pediatric surgical care. While policies evolve, additional research is needed to determine the effect of these changes on patient and healthcare delivery outcomes. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Martha-Conley E Ingram
- 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
- 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
| | - Christopher Newton
- Division of Pediatric Surgery, Department of Surgery, UCSF Benioff Children's Hospital, Oakland, CA
| | - Monica E Lopez
- Division of Pediatric Surgery, Department of Surgery, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Loren Berman
- Division of Pediatric Surgery, Department of Surgery, Sidney Kimmel Medical College at Thomas Jefferson University Hospital; Nemours Al duPont Hospital for Children, Wilmington, DE
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Ingram MCE, Calabro K, Polites S, McCracken C, Aspelund G, Rich BS, Ricca RL, Dasgupta R, Rothstein DH, Raval MV. Systematic Review of Disparities in Care and Outcomes in Pediatric Appendectomy. J Surg Res 2020; 249:42-49. [PMID: 31918329 DOI: 10.1016/j.jss.2019.12.018] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 11/13/2019] [Accepted: 12/11/2019] [Indexed: 12/21/2022]
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Ingram MCE, Huguenard AL, Miller BA, Chern JJ. Poor correlation between head circumference and cranial ultrasound findings in premature infants with intraventricular hemorrhage. J Neurosurg Pediatr 2014; 14:184-9. [PMID: 24950469 DOI: 10.3171/2014.5.peds13602] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Intraventricular hemorrhage (IVH) is the most common cause of hydrocephalus in the pediatric population and is particularly common in preterm infants. The decision to place a ventriculoperitoneal shunt or ventricular access device is based on physical examination findings and radiographic imaging. The authors undertook this study to determine if head circumference (HC) measurements correlated with the Evans ratio (ER) and if changes in ventricular size could be detected by HC measurements. METHODS All cranial ultrasound (CUS) reports at the authors' institution between 2008 and 2011 were queried for terms related to hydrocephalus and IVH, from which a patient cohort was determined. A review of radiology reports, HC measurements, operative interventions, and significant clinical events was performed for each patient in the study. Additional radiographic measurements, such as an ER, were calculated by the authors. Significance was set at a statistical threshold of p < 0.05 for this study. RESULTS One hundred forty-four patients were studied, of which 45 (31%) underwent CSF diversion. The mean gestational age and birth weight did not differ between patients who did and those who did not undergo CSF diversion. The CSF diversion procedures were reserved almost entirely for patients with IVH categorized as Grade III or IV. Both initial ER and HC were significantly larger for patients who underwent CSF diversion. The average ER and HC at presentation were 0.59 and 28.2 cm, respectively, for patients undergoing CSF diversion, and 0.34 and 25.2 cm for those who did not undergo CSF diversion. There was poor correlation between ER and HC measurements regardless of gestational age (r = 0.13). Additionally, increasing HC was not found to correlate with increasing ERs on consecutive CUSs (φ = -0.01, p = 0.90). Patients who underwent CSF diversion after being followed with multiple CUSs (10 of 45 patients) presented with smaller ERs and HC than those who underwent CSF diversion after a single CUS. Just prior to CSF diversion surgery, the patients who received multiple CUSs had ERs, but not HC measurements, that were similar to those in patients who underwent CSF diversion after a single CUS. CONCLUSIONS The HC measurement does not correlate with the ER or with changes in ER and therefore does not appear to be an adequate surrogate for serial CUSs. In patients who are followed for longer periods of time before CSF shunting procedures, the ER may play a larger role in the decision to proceed with surgery. Clinicians should be aware that the ER and HC are not surrogates for one another and may reflect different pathological processes. Future studies that take into account other physical examination findings and long-term clinical outcomes will aid in developing standardized protocols for evaluating preterm infants for ventriculoperitoneal shunt or ventricular access device placement.
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