Hospital characteristics affect outcomes for common pediatric surgical conditions.
ABSTRACT Appendicitis, hypertrophic pyloric stenosis (HPS), and intussusception are common conditions treated in most hospitals. In which hospital settings are children with these conditions treated? Are there differences in outcomes based on hospital characteristics? Our purpose was to use a nationwide database to address these questions. Data were extracted from Kids' Inpatient Database 2000. Data were queried by International Classification of Diseases procedure code for appendectomy and pyloromyotomy and by diagnosis code for intussusception. Length of stay (LOS) and hospital charges were analyzed based on hospital size, location, teaching status, and specialty designation. There were 73,618 appendectomies, with 5,910 (8%) in children's hospitals. Overall LOS was 3.1 days, and was the longest in children's hospitals (3.9). Overall charges were dollar 10,562, with the highest in children's hospitals (dollar 14,124). There were 11,070 pyloromyotomies, with 2,960 (27%) in children's hospitals. Overall LOS was 2.7 days, the shortest being in children's hospitals (2.5). Overall charges were dollar 7,938, with the highest in children's hospitals (dollar 8,676). There were 2,677 intussusceptions, with 921 (34%) in children's hospitals. Overall LOS was 3.0 days, the shortest being in children's hospitals (2.8). Overall charges were dollar 9,558, with the highest in children's hospitals (dollar 10,844). Most children with appendicitis, HPS, and intussusception are treated in nonspecialty hospitals. HPS (27%) and intussusception (34%) are more likely than appendicitis (8%) to be treated in children's hospitals. Children's hospitals have higher charges for all three conditions despite shorter LOS for HPS and intussusception.
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ABSTRACT: The United States’ healthcare system is facing unprecedented pressures: the healthcare cost curve is not sustainable while the bar of standards and expectations for the quality of care continues to rise. Systems committed to the surgical treatment of children will likely require changes and reorganization. Regardless of these mounting pressures, hospitals must remain focused on providing the best possible care to each child at every encounter. Available clinical expertise and hospital resources should be optimized to match the complexity of the treated condition. Although precise criteria are lacking, there is a growing consensus that the optimal combination of clinical experience and hospital resources must be defined, and efforts toward this goal have been supported by the Regents of the American College of Surgeons, the members of the American Pediatric Surgical Association, and the Society for Pediatric Anesthesia (SPA) Board of Directors. The topic of optimizing outcomes and the discussion of the concepts involved has unfortunately become divisive. Our goal, therefore, is 1) to provide a review of the literature that can provide context for the discussion of regionalization, volume, and optimal resources and promote mutual understanding of these important terms, 2) to review the evidence that has been published to date in pediatric surgery associated with regionalization, volume, and resource, 3) to focus on a specific resource (anesthesia), and the association that this may have with outcomes, and 4) to provide a framework for future research and policy efforts.Journal of Pediatric Surgery 05/2014; DOI:10.1016/j.jpedsurg.2014.02.085 · 1.31 Impact Factor
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ABSTRACT: The aim of the study is to evaluate a large series of infantile hypertrophic pyloric stenosis (IHPS) patients treated by one pediatric surgeon focusing on their diagnostic difficulties and complications. From July 1969 to December 2003 (inclusive), the charts of 791 infants with IHPS were retrospectively reviewed. There were 647 (82 %) males and 144 (18 %) females; mean age was 38 days, median 51 (range 7 days-10 months). When ultrasonography (US) was routinely used (1990), the age at diagnosis decreased to <40 days. The mean weight before and after routine US was 3.2 kg, median 3 (range 1.5-6). Twenty-five (3.1 %) were premature at diagnosis, mean age 49 days, median 56, (range 1-3 months) and mean weight 2.5 kg, median 2.3 (range 1.5-3.2). Eighty-one (10 %) had a positive family history. Forty-four (5 %) were non-Caucasians. Seventy-five (9 %) had other medical conditions, anomalies and/or associated findings. Sixty (7 %) patients had abnormal preoperative electrolytes. Ten (1.2 %) pylorics occurred after newborn operations. Of the entire total (791) who were treated, there were 13 (1.7 %) not operated on. All operations were done open initially through one of two right upper quadrant incisions, and then through an upper midline incision under general endotracheal anesthesia; 14 (1.7 %) had concomitant procedures. Prophylactic antibiotics (from 1982) decreased the wound infection rate to 3.9 %. There were a total of 87 (10 %) complications which included 9 (1.1 %) intraoperative, (including mistaken diagnoses) 78 (9 %) postoperative: 59 (2 %) early (<1 month) and 19 (2.4 %) late (>1 month). The 13 (1.6 %) postoperative transfers (12 from non-pediatric surgeons) had 16 (18 %) complications (including 1 death); five (33 %) requiring reoperation (4 incomplete, 1 perforation). There were two deaths. IHPS should be considered in any vomiting infant. US allows earlier diagnosis. Serious complications are uncommon and avoidable, but recognizable and easily corrected. Higher surgeon volume of pyloromyotomies (>14 per year) is associated with fewer complications.Pediatric Surgery International 03/2014; 30(5). DOI:10.1007/s00383-014-3488-8 · 1.06 Impact Factor
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ABSTRACT: Background: The aim of this study was to examine national outcomes in newborn patients with esophageal atresia and tracheoesophageal fistula (EA/TEF) in the United Sates. Methods: Kid's Inpatient Database (KID) is designed to identify, track, and analyze national outcomes for hospitalized children in the United States. Inpatient admissions for pediatric patients with EA/TEF for kid's Inpatient Database years 2000, 2003, 2006, and 2009 were analyzed. Patient demographics, socioeconomic measures, disposition, survival and surgical procedures performed were analyzed using standard statistical methods. Results: A total of 4168 cases were identified with diagnosis of EA/TEF. The overall in-hospital mortality was 9%. Univariate analysis revealed lower survival inpatients with associated acute respiratory distress syndrome, ventricular septal defect (VSD), birth weight (BW) < 1500 g, gestational age (GA), time of operation within 24 h of admission, coexisting renal anomaly, imperforate anus, African American race, and lowest economic status. Multivariate logistic regression identified BW < 1500 g (odds ratio [OR] 4.5, P < 0.001), operation within 24 h (OR 6.9, P< 0.001), GA< 28wk(OR 2.2, P< 0.030), and presence ofVSD(OR 3.8, P< 0.001) as independent predictors of in-hospital mortality. Children's general hospital and children's unit in a general hospital were found to have a lower mortality rate compared with not identified as a children's hospital after excluding immediate transfers (P=0.008). Conclusions: BW < 1500 g, operation within 24 h, GA < 28 wk, and presence of VSD are the factors that predict higher mortality in EA/TEF population. Despite dealing with more complicated cases, children's general hospital and children's unit in a general hospital were able to achieve a lower mortality rate than not identified as a children's hospital.Journal of Surgical Research 04/2014; 190(2). DOI:10.1016/j.jss.2014.04.033 · 2.12 Impact Factor