Necrotizing enterocolitis requiring surgery: outcomes by intestinal location of disease in 4371 infants
ABSTRACT The objective of this study was to determine whether the outcomes of infants with surgically managed necrotizing enterocolitis (NEC) differ according to whether the location of NEC is in the small bowel, large bowel, or both.
A retrospective analysis was performed using the Healthcare Cost and Utilization Project Nationwide Inpatient Sample and Kids' Inpatient Database. A total of 5374 infants identified as having undergone surgical management of NEC were stratified by location of bowel affected as small bowel (SB) only, large bowel (LB) only, or both small and large bowel (SB&LB). The type of surgical operation performed was used as a proxy for the location of bowel affected.
Of the 5374 infants with a diagnosis of NEC, 4371 had an operation that allowed for stratification by location. The LB group (n = 963) fared the best in all outcomes. The SB group (n = 2126) had the longest length of stay and highest total hospital charges, and mortality was comparable with that of the SB&LB group (n = 1282).
Mortality, length of stay, and total hospital charges varied according to location of bowel affected by NEC.
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ABSTRACT: Objective:Better measures are needed to identify infants at risk for developing necrotizing enterocolitis (NEC) and facilitate communication about risk across transitions. Although NEC is multi-factorial, quantification of composite risk for NEC in an individual infant is not clearly defined. The objective of this study was to describe the derivation, validation and calibration testing of a novel clinical NEC risk index, GutCheck(NEC). Individual risk factors were weighted to assess composite odds of developing NEC. GutCheck(NEC) is designed to improve communication about NEC risk and coordination of care among clinicians across an infant's clinical course.Study design:On the basis of a synthesis of research evidence about NEC risk and an e-Delphi study including 35 neonatal experts, we identified NEC risk factors believed by the experts to be most relevant for a NEC risk index, then applied a logistic model building process to derive and validate GutCheck(NEC). De-identified data from the Pediatrix BabySteps Clinical Data Warehouse (discharge date 2007 to 2011) were split into three samples for derivation, validation and calibration. By comparing infants with medical NEC, surgical NEC and those who died to infants without NEC, we derived the logistic model using the un-matched derivation set. Discrimination was then tested in a case-control matched validation set and an un-matched calibration set using receiver operating characteristic curves.Result:Sampled from a cohort of 58 820 infants, the randomly selected derivation set (n=35 013) revealed nine independent risk factors (gestational age, history of packed red blood cell transfusion, unit NEC rate, late-onset sepsis, multiple infections, hypotension treated with inotropic medications, Black or Hispanic race, outborn status and metabolic acidosis) and two risk reducers (human milk feeding on both days 7 and 14 of life, and probiotics). Unit NEC rate carried the most weight in the summed score. Validation using a 2:1 matched case-control sample (n=360) demonstrated fair to good discrimination. In the calibration set (n=23 447), GutCheck(NEC) scores (range 0 to 58) discriminated those infants who developed surgical NEC (area under the curve (AUC)=0.84, 95% confidence interval (CI) 0.82 to 0.84) and NEC leading to death (AUC=0.83, 95% CI 0.81 to 0.85), more accurately than medical NEC (AUC= 0.72, 95% CI 0.70 to 0.74).Conclusion:GutCheck(NEC) represents weighted composite risk for NEC and discriminated infants who developed NEC from those who did not with very good accuracy. We speculate that targeting modifiable NEC risk factors could reduce national NEC prevalence.Journal of Perinatology advance online publication, 20 March 2014; doi:10.1038/jp.2014.37.Journal of perinatology: official journal of the California Perinatal Association 03/2014; 34(6). DOI:10.1038/jp.2014.37 · 2.35 Impact Factor
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ABSTRACT: The purpose of this qualitative descriptive study was to provide rich description of experts’ perspectives about necrotizing enterocolitis risk. Comments from 35 NEC experts were coded by two reviewers, grouped into categories and organized into themes. From 93 category codes, 9 meta-categories, and two broad themes were derived. NEC risk was considered to arise from both individual factors of vulnerability and variation in neonatal care practices. Controversy arose about the role of Patent Ductus Arteriosus (PDA) and its treatment, transfusions, risk differences based on gestational age, efficacy and safety of probiotics in prevention, and the role of antibiotic exposure and multiple infections. Experts indicated the need for a stronger evidence base about NEC risk yet experts cited a lack of a strong evidence base on occasion when good to high quality evidence was available.Newborn and Infant Nursing Reviews 09/2014; DOI:10.1053/j.nainr.2014.06.004
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ABSTRACT: A primary determinant of value in treating appendicitis is inpatient cost. The purpose of this study was to identify hospital-level factors that drive costs associated with the treatment of appendicitis. Cost-to-charge ratios from the 2009 Kids' Inpatient Database gave average all-payer costs by hospital for uncomplicated appendicitis (without peritonitis, ICD-9-CM 540.9) and complicated appendicitis (generalized peritonitis, 540.0; peritoneal abscess, 540.1). The 10% of hospitals with the lowest costs were defined as low cost; the remaining 90% were defined non-low cost. Bivariate and multivariate analyses compared hospital characteristics between the two groups. Threshold cost dividing low cost from non-low cost for uncomplicated appendicitis was $4626; for complicated appendicitis, it was $6,026. For both conditions teaching status, lower percentage of pediatric discharges, and fewer registered nurses (RN) per 1000 adjusted patient-days predicted a hospital to be low cost. A cost benefit for medium and large hospitals and higher inpatient volume was found only for uncomplicated appendicitis. Regional effects were noted. The findings show the high-cost structure of hospitals that care for high volumes of children, emphasizing the need to constrain cost. There is some benefit of economies of scale, and careful attention to the numbers of nursing personnel.Journal of Pediatric Surgery 11/2013; 48(11):2320-6. DOI:10.1016/j.jpedsurg.2013.06.003 · 1.31 Impact Factor