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Baxter KJ, Nguyen HTMH, Wulkan ML, Raval MV. Association of Health Care Utilization With Rates of Perforated Appendicitis in Children 18 Years or Younger. JAMA Surg 2019; 153:544-550. [PMID: 29387882 DOI: 10.1001/jamasurg.2017.5316] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Importance The pediatric perforated appendix rate is a quality metric measured by the Agency for Healthcare Research and Quality (AHRQ) that reflects access to care. The association of health care utilization prior to presentation with appendicitis is unknown. Objective To determine whether increased health care utilization prior to presentation with appendicitis is associated with lower perforated appendicitis rates in children. Design, Setting, and Participants Retrospective cohort study of privately insured children drawn from large employer and insurance company administrative data found in the Truven MarketScan national insurance claims database. Cases of appendicitis were identified among 38 348 children 18 years or younger from January 1, 2010, through December 31, 2013, with corresponding primary health care encounters from January 1, 2009, through December 31, 2012. In all, 19 109 eligible children were identified using International Classification of Diseases, Ninth Revision (ICD-9) diagnosis codes for appendicitis after excluding those patients who did not have continuous insurance coverage during the study period. Statistical analysis was performed from September 1, 2016, to October 15, 2017. Exposures Health care utilization was determined by the number of outpatient clinic encounters for each patient in the 1 to 12 months before presentation with appendicitis. Main Outcomes and Measures Perforated appendicitis was defined according to the AHRQ by using ICD-9 codes for perforation and hospital length of stay of 3 or more days. Logistic regression models were used for perforated appendicitis after adjustment for age, sex, income, gastrointestinal comorbidities, geographic region, and insurance type. Results We identified 38 348 children 18 years or younger with ICD-9 diagnosis codes for appendicitis, and 19 109 children remained for analysis after applying exclusion criteria. Of these, 11 422 were boys (59.8%); the mean (SD) age was 12.4 (3.9) years. Of the 19 109 children identified who underwent appendectomy, 5509 (28.8%) presented with perforated appendicitis. Children with perforation had lower outpatient health care utilization in the year before presentation compared with those diagnosed with acute appendicitis (4554 of 5509 children [82.7%] vs 11 937 of 13 600 [87.8%]; P < .001). In the adjusted model, outpatient health care utilization before presentation was associated with lower odds of perforated appendicitis (odds ratio [OR], 0.63; 95% CI, 0.58-0.69; P < .001). This association increased with visit frequency in the year before presentation (OR, 0.86; 95% CI, 0.77-0.95 for 1-2 visits, P = .003; OR, 0.61; 95% CI, 0.55-0.67 for 3-6 visits, P < .001; and OR, 0.43; 95% CI, 0.38-0.48 for ≥7 visits [5-18 years], P < .001). Covariates associated with perforation included younger age, geographic region, family income, and higher out-of-pocket insurance plans. Conclusions and Relevance Among insured children 18 years or younger, increased health care utilization was associated with lower rates of perforated appendicitis. Primary health care relationships may facilitate timely presentation or serve as a marker for health-related self-efficacy, thereby contributing to outcomes for acute surgical conditions.
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Affiliation(s)
- Katherine J Baxter
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia.,Division of Pediatric Surgery, Department of Surgery, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Hannah T M H Nguyen
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia.,Division of Pediatric Surgery, Department of Surgery, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Mark L Wulkan
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia.,Division of Pediatric Surgery, Department of Surgery, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Mehul V Raval
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia.,Division of Pediatric Surgery, Department of Surgery, Children's Healthcare of Atlanta, Atlanta, Georgia
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Goldstein SD, Raval MV. Medical Overuse and Appendicitis Treatment. JAMA Pediatr 2019; 173:891-892. [PMID: 31329222 DOI: 10.1001/jamapediatrics.2019.2394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Seth D Goldstein
- Pediatric General and Thoracic Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.,Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Mehul V Raval
- Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois.,Surgical Outcomes and Quality Improvement Center, Center for Healthcare Studies, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois.,Surgical Quality Improvement System Lead, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
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Rizeq YK, Many BT, Vacek JC, Silver I, Goldstein SD, Abdullah F, Raval MV. Trends in perioperative opioid and non-opioid utilization during ambulatory surgery in children. Surgery 2019; 166:172-176. [DOI: 10.1016/j.surg.2019.04.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 03/12/2019] [Accepted: 04/02/2019] [Indexed: 10/26/2022]
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Baxter KJ, Short HL, Wetzel M, Steinberg RS, Heiss KF, Raval MV. Decreased opioid prescribing in children using an enhanced recovery protocol. J Pediatr Surg 2019; 54:1104-1107. [PMID: 30885561 DOI: 10.1016/j.jpedsurg.2019.02.044] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [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] [Received: 01/31/2019] [Accepted: 02/21/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND A previously implemented Enhanced Recovery Protocol (ERP) for children undergoing elective gastrointestinal operations demonstrated decreased length of stay (LOS) and in-hospital opioid use. We hypothesized that the ERP would be associated with decreased postdischarge opioid prescribing. METHODS Demographic, operative, and opioid prescription data were retrospectively compared between elective gastrointestinal surgical patients in the pre-ERP (1/2012-12/2014) and the post-ERP periods (1/2015-12/2017). RESULTS Of the 99 patients reviewed, 56 (56.7%) were treated in the post-ERP era. Overall, 48 (48.5%) were male, and the most common operation was partial or total colectomy (n = 39, 39.4%) followed by ileocecectomy (n = 26, 26.3%). Most patients were 15-16 years of age and had inflammatory bowel disease (n = 88, 88.9%). LOS decreased from a median 4 days pre-ERP to 3 days post-ERP (p = 0.02). Patients receiving intraoperative opioids decreased from 100% to 46% (p < 0.01) and postoperative opioids from 95% to 59% (p < 0.01). Patients receiving an opioid prescription at discharge decreased from 69.8% pre-ERP to 30.9% post-ERP (p < 0.01). Among patients prescribed opioids at discharge, the number of doses (median 23 to 17, p = 0.44) and the median morphine equivalents/kg remained stable (median 2.3 to 1.7, p = 0.10). CONCLUSIONS A pediatric gastrointestinal surgery ERP resulted in decreased postdischarge prescribing of opioids. TYPE OF STUDY Retrospective cohort study. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Katherine J Baxter
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA
| | - Heather L Short
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA
| | - Martha Wetzel
- Department of Pediatrics, Emory University School of Medicine, Children's Hospital of Atlanta, Atlanta, GA
| | - Rebecca S Steinberg
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA
| | - Kurt F Heiss
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA
| | - 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.
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Tessler RA, Dellinger M, Richards MK, Goldin AB, Beierle EA, Doski JJ, Goldfarb M, Langer M, Nuchtern JG, Raval MV, Vasudevan S, Gow KW. Pediatric gastric adenocarcinoma: A National Cancer Data Base review. J Pediatr Surg 2019; 54:1029-1034. [PMID: 30824240 DOI: 10.1016/j.jpedsurg.2019.01.048] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [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: 01/24/2019] [Accepted: 01/27/2019] [Indexed: 02/07/2023]
Abstract
PURPOSE We sought to compare the presentation, management, and outcomes in gastric adenocarcinoma cancer for pediatric and adult patients. METHODS Using the 2004 to 2014 National Cancer Database (NCDB), patients ≤21 years (pediatric) were retrospectively compared to >21 years (adult). Chi-squared tests were used to compare categorical variables, and Cox regression was used to estimate hazard ratios (HR) for survival differences. RESULTS Of the 129,024 gastric adenocarcinoma cases identified, 129 (0.10%) occurred in pediatric patients. Pediatric cases presented with more advanced disease, including poorly differentiated tumors (81% vs 65%, p = 0.006) and stage 4 disease (56% vs 41%, p = 0.002). Signet ring adenocarcinoma comprised 45% of cases in the pediatric group as compared to 20% of cases in the adults (P < 0.001). Similar proportions in both groups underwent surgery. However, near-total gastrectomy was more common in the pediatric group (16% vs 6%, p < 0.001). The proportions of patients with negative margins, nodal examination, and presence of positive nodes were similar. There was no overall survival difference between the two age groups (HR 0.92, 95% Confidence interval 0.73-1.15). CONCLUSION While gastric adenocarcinoma in pediatric patients present with a more advanced stage and poorly differentiated tumors compared to adults, survival appears to be comparable. TYPE OF STUDY Retrospective cohort study. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Robert A Tessler
- Seattle Children's Hospital, Division of General and Thoracic Surgery, Seattle, WA; University of Washington Harborview Injury Prevention and Research Center, Seattle, WA; University of Pittsburgh, Department of Surgery, Pittsburgh, PA
| | - Matthew Dellinger
- Seattle Children's Hospital, Division of General and Thoracic Surgery, Seattle, WA
| | - Morgan K Richards
- Seattle Children's Hospital, Division of General and Thoracic Surgery, Seattle, WA
| | - Adam B Goldin
- Seattle Children's Hospital, Division of General and Thoracic Surgery, Seattle, WA
| | | | - John J Doski
- UT Health Science Center San Antonio, San Antonio, TX
| | | | - Monica Langer
- Ann & Robert H. Lurie Children's Hospital of Chicago, Pediatric Surgery, Chicago, IL
| | - Jed G Nuchtern
- Texas Children's Hospital, Pediatric Surgery, Houston, TX
| | | | | | - Kenneth W Gow
- Seattle Children's Hospital, Division of General and Thoracic Surgery, Seattle, WA.
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Morsberger JL, Short HL, Baxter KJ, Travers C, Clifton MS, Durham MM, Raval MV. Parent reported long-term quality of life outcomes in children after congenital diaphragmatic hernia repair. J Pediatr Surg 2019; 54:645-650. [PMID: 29970249 DOI: 10.1016/j.jpedsurg.2018.06.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [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: 03/08/2018] [Revised: 05/18/2018] [Accepted: 06/04/2018] [Indexed: 02/07/2023]
Abstract
PURPOSE The aim of this study was to determine long-term outcomes for congenital diaphragmatic hernia (CDH) patients including quality of life (QoL), symptom burden, reoperation rates, and health status. METHODS A chart review and phone QoL survey were performed for patients who underwent CDH repair between 2007 and 2014 at a tertiary free-standing children's hospital. Comprehensive outcomes were collected including subsequent operations and health status. Associations with QoL were tested using Wilcoxon Rank-Sum tests and Pearson correlation coefficients. RESULTS Of 102 CDH patients identified, 46 (45.1%) patient guardians agreed to participate with mean patient age of 5.8 (SD, 2.2) years at time of follow-up. Median PedsQLTM and PedsQLTM Gastrointestinal scores were 91.8 (IQR, 84.8-95.8) and 95.8 (IQR, 93.0-98.2), out of 100. Thoracoscopic repair was associated with higher PedsQLTM scores while defects with an intrathoracic stomach were associated with increased gas and bloating. No difference in QoL was found when comparing defect side, patch vs primary repair, prenatal diagnosis, extracorporeal membrane oxygenation, or recurrence. Older age weakly correlated with worse school functioning and heartburn. CONCLUSION Children with CDH have reassuring QoL scores. Given the correlation between older age and poor school function, longer follow-up of patients with CDH may be warranted. LEVEL OF EVIDENCE III (Retrospective comparative study).
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Affiliation(s)
- Jill L Morsberger
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA
| | - Heather L Short
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA
| | - Katherine J Baxter
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA
| | - Curtis Travers
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA
| | - Matthew S Clifton
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA
| | - Megan M Durham
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA
| | - Mehul V Raval
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA.
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Hillyer MM, Baxter KJ, Clifton MS, Gillespie SE, Bryan LN, Travers CD, Raval MV. Primary versus secondary anastomosis in intestinal atresia. J Pediatr Surg 2019; 54:417-422. [PMID: 29880397 DOI: 10.1016/j.jpedsurg.2018.05.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [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: 01/16/2018] [Revised: 04/26/2018] [Accepted: 05/07/2018] [Indexed: 11/17/2022]
Abstract
PURPOSE Neonates with intestinal atresia (IA) undergo either primary anastomosis (PA) or ostomy creation with secondary anastomosis (SA). Our purpose was to compare outcomes for PA and SA and to assess factors influencing procedure selection. METHODS We conducted a retrospective cohort study of neonates with IA between 2009 and 2015. Patient characteristics, operative details, and outcomes were collected. Surgeon-level preferences (defined as performing >50% PA or SA) were assessed using logistic regression. RESULTS Of 92 IA patients, 70 (76.1%) underwent PA and 22 (23.9%) underwent SA. Neonates with PA had shorter hospitalizations (27 days vs. 95 days, p < 0.001), shorter total parenteral nutrition duration (19 days vs. 74.5 days, p < 0.001), and fewer readmissions (33.3% vs. 63.2%, p = 0.024). On multivariable regression analysis, higher Apgar scores (Odds Ratio (OR) 4.16, 95% Confidence Interval (CI) 1.20-14.29) and uncomplicated atresia (OR 3.97, 95% CI 1.37-11.48) were associated with PA. At the surgeon-level, utilization of PA varied from 43.5% to 100%. Surgeon preference is not influenced by the demographic, presentation, or surgical findings of this patient population. CONCLUSIONS PA has better outcomes than SA. Though procedural selection is influenced by the clinical status of the neonate, however surgeon preference plays a significant role in this clinical decision. LEVEL OF EVIDENCE Level III Treatment Study.
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Affiliation(s)
- Margot M Hillyer
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Katherine J Baxter
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Matthew S Clifton
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Scott E Gillespie
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Leah N Bryan
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Curtis D Travers
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Mehul V Raval
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA.
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Berman L, Raval MV, Ottosen M, Mackow AK, Cho M, Goldin AB. Parent Perspectives on Readiness for Discharge Home after Neonatal Intensive Care Unit Admission. J Pediatr 2019; 205:98-104.e4. [PMID: 30291021 DOI: 10.1016/j.jpeds.2018.08.086] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [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: 06/14/2018] [Revised: 08/09/2018] [Accepted: 08/31/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE To explore the parent perspective on discharge home from the neonatal intensive care unit (NICU). STUDY DESIGN We interviewed parents of NICU graduates with a range of demographic characteristics and medical complexities to explore parent perspectives on readiness for discharge. Interviews were transcribed and coded by a 6-member team. We performed content analysis to identify themes and develop a family-centered conceptual framework around readiness for NICU discharge. RESULTS We interviewed a total of 15 parents who experienced NICU stays with 18 infants. Parents who have experienced NICU discharge have a spectrum of needs that evolve from the time the child is in the NICU, at time of discharge, and at home afterward. These needs consistently centered around 5 themes-communication, parent role clarity, emotional support, knowledge sources, and financial resources. CONCLUSIONS Parents described many ways the system could have better prepared them and connected them with essential resources. Summarizing the voices of the parents who participated in this study, we have compiled a series of practical recommendations for clinicians to use in daily practice to help parents feel prepared and confident for the transition home from the NICU.
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Affiliation(s)
- Loren Berman
- Department of Surgery, Division of General Pediatric Surgery, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA; Department of Surgery, Division of General Pediatric Surgery, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE.
| | - Mehul V Raval
- Department of Surgery, Division of General Pediatric Surgery, Emory University, Children's Healthcare of Atlanta, Atlanta, GA
| | - Madelene Ottosen
- Department of Surgery, Division of General Pediatric Surgery, University of Texas Houston-Memorial Hermann Center for Healthcare Quality and Safety, Houston, TX
| | - Anne Kim Mackow
- Department of Surgery, Division of General Pediatric Surgery, Rainbow Babies and Children, Cleveland, OH
| | | | - Adam B Goldin
- Department of Surgery, Division of General Pediatric Surgery, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA
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Edney JC, Lam H, Raval MV, Heiss KF, Austin TM. Implementation of an enhanced recovery program in pediatric laparoscopic colorectal patients does not worsen analgesia despite reduced perioperative opioids: a retrospective, matched, non-inferiority study. Reg Anesth Pain Med 2019; 44:123-129. [DOI: 10.1136/rapm-2018-000017] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 06/12/2018] [Accepted: 06/18/2018] [Indexed: 12/15/2022]
Abstract
Background and objectivesEnhanced recovery protocols (ERPs) decrease length of stay and postoperative morbidity, but it is important that these benefits do not come at a cost of sacrificing proper perioperative analgesia. In this retrospective, matched cohort study, we evaluated postoperative pain intensity in pediatric patients who underwent laparoscopic colorectal surgeries before and after ERP implementation.MethodsPatients in each cohort were randomly matched based on age, diagnosis, American Society of Anesthesiologists classification, and surgical procedure. The primary outcome was average daily postoperative pain score, while the secondary outcomes included postoperative hospital length of stay, complication rate, and 30-day readmissions. Since our hypothesis was non-inferior analgesia in the postprotocol cohort, a non-inferiority study design was used.ResultsAfter matching, 36 pairs of preprotocol and postprotocol patients were evaluated. ERP patients had non-inferior recovery room pain scores (difference 0 (−1.19, 0) points, 95% CI −0.22 to 0.26 points, p valuenon-inferiority <0.001) and 4-day postoperative pain scores (difference −0.3±1.9 points, 95% CI −0.82 to 0.48 points, p valuenon-inferiority <0.001) while receiving less postoperative opioids (difference −0.15 [−0.21, –0.05] intravenous morphine equivalents/kg/day, p<0.001). ERP patients also had reduced postoperative hospital stays (difference −1.5 [−4.5, 0] days, p<0.001) and 30-day readmissions (2.8% vs 27.8%, p=0.008).ConclusionsImplementation of our ERP for pediatric laparoscopic colorectal patients was associated with less perioperative opioids without worsening postoperative pain scores. In addition, patients who received the protocol had faster return of bowel function, shorter postoperative hospital stays, and a lower rate of 30-day hospital readmissions. In pediatric laparoscopic colorectal patients, the incorporation of an ERP was associated with a pronounced decrease in perioperative morbidity without sacrificing postoperative analgesia.
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Ji D, Goudy SL, Raval MV, Raol N. Pediatric Surgical Risk Assessment Tools: A Systematic Review. J Surg Res 2018; 234:277-282. [PMID: 30527485 DOI: 10.1016/j.jss.2018.09.051] [Citation(s) in RCA: 2] [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] [Received: 02/28/2018] [Revised: 06/23/2018] [Accepted: 09/13/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND Pediatric surgical risk assessment tools use patient- and procedure-specific variables to predict postoperative complications. These tools assist clinicians in preoperative counseling and surgical decision-making. The objective of this systematic literature review was to compile and compare existing pediatric surgical risk tools that are broadly applicable across pediatric surgical specialties. METHODS A systematic literature review was performed following the Preferred Reporting Items for Systematic Reviews (PRISMA) guidelines. Relevant publications were identified and screened based on predefined eligibility criteria: (1) a preoperative risk assessment tool predicting postoperative complications or mortality, (2) applicable across various surgical specialties, and (3) pertinent to the pediatric population. Studies with specialty- or procedure-specific risk scores and validation studies were excluded. Included articles were assessed for quality and risk of bias by using the Newcastle-Ottawa Scale. RESULTS Four studies met inclusion criteria. Risk factors were evaluated across the models as proxies for operative suitability of patients before surgery. Risk factors common to all studies were the presence of cardiovascular or neurological diseases and history of prematurity. Three of the four included studies defined most risk factors in binary terms, whereas one study used a scale of severity of organ system disease when defining preoperative risk. Generated risk score models provided good to strong concordance with inpatient mortality or postoperative complications, with c-statistic values ranging from 0.77 to 0.98. CONCLUSIONS Each study reported an assessment of a novel, generally applicable pediatric surgical risk assessment tool for risk-stratifying children preoperatively for complications that rise after surgery. More studies are needed to assess generalizability in all populations and procedures.
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Affiliation(s)
- Dabin Ji
- Mercer University School of Medicine, Savannah, Georgia
| | - Steven L Goudy
- Division of Pediatric Otolaryngology, Department of Otolaryngology-Head and Neck Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Mehul V Raval
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Nikhila Raol
- Division of Pediatric Otolaryngology, Department of Otolaryngology-Head and Neck Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia.
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Abstract
Quality improvement (QI) is the practice of continuously evaluating and improving the quality of health care that is delivered to patients. In this article, we will use practical examples to show how quality improvement projects have improved surgical patient care, and can be shared between institutions to accelerate the pace of improvement. We will explain the differences between quality improvement and research, and describe the methodological approach to performing and reporting quality improvement projects. Finally, we will describe ways to disseminate and widely implement changes in clinical practice using QI methodology. Even if they are not initiating and developing QI projects, all surgeons are likely to be affected by improvement initiatives going on in their hospitals, and should understand their valuable contribution to patient care.
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Affiliation(s)
- Loren Berman
- Division of Pediatric Surgery, Department of Surgery, Thomas Jefferson University, Philadelphia, PA and Nemours-AI DuPont Hospital for Children, Wilmington, DE, 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, USA
| | - Adam Goldin
- University of Washington School of Medicine, Division of Pediatric General and Thoracic Surgery, Seattle Children's Hospital, OFFICE 4800 Sand Point Way NE, Seattle, WA 98105. MAIL M/S W-7729, PO Box 5371, Seattle, WA, 98105, USA.
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Abstract
Clinical registries provide a valuable opportunity to study specific diagnoses or conditions with a broader scope than possible using individual center-based series and with more clinical detail than typically available in administrative data sources. These registries amass structured data with uniform definitions, thus facilitating reliable adoption and consistent use across contributing sites. By compiling granular data from a multitude of geographically diverse sites, clinical registries allow investigation of rare outcomes, comparison of practice and cost variation, and benchmarking across institutions. Registries may track cohorts of patients over time, providing unique longitudinal follow-up that cannot be obtained from many alternate data sources. As clinical registries become more prevalent, research conducted using these registries is increasing and helping to expand knowledge boundaries in children's surgery. The purpose of this review is to provide an overview of several of the most common clinical registries used in children's surgery and explore the strengths and limits of these tools in the conduct of meaningful health services research.
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Affiliation(s)
- Ferdynand Hebal
- Division of Pediatric Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago and the Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Yue-Yung Hu
- Division of Pediatric Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago and the Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Mehul V Raval
- Division of Pediatric Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago and the Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.
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Short HL, Sarda S, Travers C, Hockenberry J, McCarthy I, Raval MV. Pediatric Inpatient-Status Volume and Cost at Children's and Nonchildren's Hospitals in the United States: 2000-2009. Hosp Pediatr 2018; 8:753-760. [PMID: 30409769 DOI: 10.1542/hpeds.2017-0152] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
OBJECTIVES The evolving role of children's hospitals (CHs) in the setting of rising health care costs has not been fully explored. We compared pediatric inpatient discharge volumes and costs by hospital type and examined the impact of care complexity and hospital-level factors on costs. METHODS A retrospective, cross-sectional study of care between 2000 and 2009 was performed by using the Kids' Inpatient Database. Weighted discharge data were used to generate national estimates for a comparison of inpatient volume, cost, and complexity at CHs and nonchildren's hospitals (NCHs). Linear regression was used to assess how complexity, payer mix, and hospital-level characteristics affected inflation-adjusted costs. RESULTS Between 2000 and 2009, the number of discharges per 1000 children increased from 6.3 to 7.7 at CHs and dropped from 55.4 to 53.3 at NCHs. The proportion of discharges at CHs grew by 6.8% between 2006 and 2009 alone. In 2009, CHs were responsible for 12.6% (95% confidence interval: 10.4%-14.9%) of pediatric discharges and 14.7% of major therapeutic procedures, yet they accounted for 23.0% of inpatient costs. Costs per discharge were significantly higher at CHs than at NCHs for all years (P < .001); however, the increase in costs seen over time was not significant. Care complexity increased during the study period at both CHs and NCH, but it could not be used to fully account for the difference in costs. CONCLUSIONS National trends reveal a small rise in both the proportion of inpatient discharges and the hospital costs at CHs, with costs being significantly higher at CHs than at NCHs. Research into factors influencing costs and the role of CHs is needed to inform policy and contain costs.
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Affiliation(s)
- Heather L Short
- Children's Healthcare of Atlanta, Atlanta, Georgia;
- Division of Pediatric Surgery, Departments of Surgery and
| | - Samir Sarda
- Department of Health Policy and Management, Rollins School of Public Health, and
| | - Curtis Travers
- Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Jason Hockenberry
- Department of Health Policy and Management, Rollins School of Public Health, and
| | - Ian McCarthy
- Department of Economics, Emory University, Atlanta, Georgia; and
| | - Mehul V Raval
- Division of Pediatric Surgery, Department of Surgery, Northwestern Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
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114
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Baxter KJ, Short HL, Steinberg RS, Heiss KF, Raval MV. Decreased Opioid Prescribing in Children Using an Enhanced Recovery Protocol. J Am Coll Surg 2018. [DOI: 10.1016/j.jamcollsurg.2018.07.429] [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: 10/28/2022]
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Affiliation(s)
- Martha Wetzel
- Rollins School of Public Health, Emory University, Atlanta, Georgia
| | | | - Mehul V. Raval
- Children’s Healthcare of Atlanta, Emory University, Atlanta, Georgia
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116
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Maizlin II, Dellinger M, Gow KW, Goldin AB, Goldfarb M, Nuchtern JG, Langer M, Vasudevan SA, Doski JJ, Raval MV, Beierle EA. Testicular tumors in prepubescent patients. J Pediatr Surg 2018; 53:1748-1752. [PMID: 29102152 DOI: 10.1016/j.jpedsurg.2017.09.020] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [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: 06/27/2017] [Revised: 09/14/2017] [Accepted: 09/18/2017] [Indexed: 11/25/2022]
Abstract
BACKGROUND/PURPOSE Pediatric testicular tumors are rare, constituting only 1% of all pediatric solid tumors. Single-institution studies addressing pediatric testicular tumors published to date have been limited in the number of patients. METHODS We utilized the National Cancer Data Base (1998-2012) to review all prepubescent patients (≤12 years old) with testicular neoplasms. Demographics, tumor characteristics, treatment modalities, and outcomes were abstracted. RESULTS A total of 479 patients were identified, with a median age of 3 years (IQR 0-4) at diagnosis. 67% of cases were diagnosed by 3 years of age. Yolk sac tumors were the most common histology (202 patients, 42.2%). Most tumors were diagnosed at a low stage. Resection was performed in 465 boys, with 75% having undergone radical orchiectomies. Chemotherapy was utilized in 28% of cases and radiotherapy in 7%. With mean follow-up of 5.6 years, mortality rate was 3%. No difference in mortality was noted based on histology or extent of surgical resection. CONCLUSIONS This series of prepubertal testicular tumors is the largest yet reported and highlights the patient demographics, tumor characteristics, treatment modalities and outcomes for these tumors. TYPE OF STUDY Prognosis study LEVEL OF EVIDENCE: II.
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Affiliation(s)
- Ilan I Maizlin
- Department of Surgery, University of Alabama at Birmingham, 1600 7th Ave S, Lowder Room 300, Birmingham, AL 35233
| | - Matthew Dellinger
- Division of Pediatric General and Thoracic Surgery, Seattle Children's Hospital, 4800 Sand, Point Way NE, Seattle, WA
| | - Kenneth W Gow
- Division of Pediatric General and Thoracic Surgery, Seattle Children's Hospital, 4800 Sand, Point Way NE, Seattle, WA
| | - Adam B Goldin
- Division of Pediatric General and Thoracic Surgery, Seattle Children's Hospital, 4800 Sand, Point Way NE, Seattle, WA
| | - Melanie Goldfarb
- Department of Surgery, John Wayne Cancer Institute at Providence St. John's Health Center, Santa Monica, CA
| | - Jed G Nuchtern
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Monica Langer
- Department of Surgery, Maine Children's Cancer Program, Tufts University, Portland, ME
| | - Sanjeev A Vasudevan
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - John J Doski
- Department of Surgery, Methodist Children's Hospital of South Texas, University of Texas Health Science Center-San Antonio, San Antonio, TX
| | - Mehul V Raval
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA
| | - Elizabeth A Beierle
- Department of Surgery, University of Alabama at Birmingham, 1600 7th Ave S, Lowder Room 300, Birmingham, AL 35233.
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117
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Jen HC, Raval MV, Langham MR, Calkins CM, Dasgupta R, Shah SR, Stafford SD, Bernstein IH, Chen LE. Attitudes and Beliefs of Pediatric Surgical Specialists on Costs of Care and High Deductible Health Plans. Am Surg 2018; 84:1410-1414. [PMID: 30268167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Health care consumers are burdened with rising out-of-pocket medical expenses. Surgical specialists' experience and attitude towards patients' out-of-pocket costs and the influence of these factors on healthcare utilization are unknown. Our aim was to define the pediatric surgeons' experience with the financial concerns of their patients. Members from the American Academy of Pediatrics Sections on Plastic Surgery, Surgery and Urology were surveyed. Analysis of variance was used to investigate practice differences. Two hundred and eighteen out of 973 surgeons representing 38 states completed the survey. Nearly half of the surveyed surgeons did not know if cost was a determinant for their patients' choice in surgical facility, or if parents compared costs prior to the visit. Eighty four per cent of the surgeons would consider patient costs if medically appropriate, to entertain less costly alternatives, and adjust surgical scheduling to decrease economic burden. Most pediatric surgical specialists are unaware if out-of-pocket costs influenced patients' preoperative decisions. Nonetheless, they are sympathetic to the issue. As the financial burden of health care shifts to consumers, our survey indicates that surgeons are open to candid discussion surrounding finances and may alter recommendations accordingly if appropriate.
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118
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Jen HC, Raval MV, Langham MR, Calkins CM, Dasgupta R, Shah SR, Stafford SD, Bernstein IH, Chen LE. Attitudes and Beliefs of Pediatric Surgical Specialists on Costs of Care and High Deductible Health Plans. Am Surg 2018. [DOI: 10.1177/000313481808400941] [Citation(s) in RCA: 3] [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: 12/14/2022]
Abstract
Health care consumers are burdened with rising out-of-pocket medical expenses. Surgical specialists’ experience and attitude towards patients’ out-of-pocket costs and the influence of these factors on healthcare utilization are unknown. Our aim was to define the pediatric surgeons’ experience with the financial concerns of their patients. Members from the American Academy of Pediatrics Sections on Plastic Surgery, Surgery and Urology were surveyed. Analysis of variance was used to investigate practice differences. Two hundred and eighteen out of 973 surgeons representing 38 states completed the survey. Nearly half of the surveyed surgeons did not know if cost was a determinant for their patients’ choice in surgical facility, or if parents compared costs prior to the visit. Eighty four per cent of the surgeons would consider patient costs if medically appropriate, to entertain less costly alternatives, and adjust surgical scheduling to decrease economic burden. Most pediatric surgical specialists are unaware if out-of-pocket costs influenced patients’ preoperative decisions. Nonetheless, they are sympathetic to the issue. As the financial burden of health care shifts to consumers, our survey indicates that surgeons are open to candid discussion surrounding finances and may alter recommendations accordingly if appropriate.
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Affiliation(s)
| | - Howard C. Jen
- From the Mattel Children's Hospital at UCLA, Los Angeles, California
| | | | - Max R. Langham
- University of Tennessee Health Science Center, Memphis, Tennessee
| | | | - Roshni Dasgupta
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | - Shawn D. Stafford
- From the Mattel Children's Hospital at UCLA, Los Angeles, California
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119
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Short HL, Sarda S, Travers C, Hockenberry JM, McCarthy I, Raval MV. Trends in common surgical procedures at children's and nonchildren's hospitals between 2000 and 2009. J Pediatr Surg 2018; 53:1472-1477. [PMID: 29241960 DOI: 10.1016/j.jpedsurg.2017.11.053] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [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: 05/25/2017] [Revised: 10/31/2017] [Accepted: 11/18/2017] [Indexed: 11/28/2022]
Abstract
PURPOSE Though growth in children's surgical expenditures has been documented, procedure-specific differences in volume and costs at children's hospitals (CH) and non-hildren's hospitals (NCH) have not been explored. Our purpose was to compare trends in volume and costs of common pediatric surgical procedures between CH and NCH. METHODS We performed a review of the 2000-2009 Kids' Inpatient Database identifying all cases of appendectomy for uncomplicated appendicitis (AP), tonsillectomy and adenoidectomy (TA), fundoplication (FP), humeral fracture repair (HFR), pyloromyotomy (PYL), and cholecystectomy (CHOLE). Trends in case volume and costs were examined at CH versus NCH. RESULTS The proportion of surgical care at CH increased for all procedures from 2000 to 2009. TA and CHOLE demonstrated higher costs per case at CH. Positive growth over time in cost per case at CH was seen for AP and FP, with the cost per case of FP increasing by 21% between 2006 and 2009. CONCLUSIONS The proportion of surgeries performed at CH is continuing to grow alongside proportionate increases in costs, however costs for certain procedures are higher at CH than NCH. Further investigation is needed to explore cost containment at CH while still maintaining specialized, high quality surgical care. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Heather L Short
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Samir Sarda
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Curtis Travers
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Jason M Hockenberry
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Ian McCarthy
- Deparment of Economics, Emory University, Atlanta, GA, USA
| | - Mehul V Raval
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA.
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Baxter KJ, Gale BF, Travers CD, Heiss KF, Raval MV. Ramifications of the Children's Surgery Verification Program for Patients and Hospitals. J Am Coll Surg 2018; 226:917-924.e1. [DOI: 10.1016/j.jamcollsurg.2018.02.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Revised: 02/05/2018] [Accepted: 02/06/2018] [Indexed: 10/18/2022]
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Abstract
As healthcare systems increasingly shift focus toward providing high-quality and high-value care to patients, there has been a simultaneous growth in assessing the patient's experience through patient-reported outcomes. Along with well-known patient reported outcomes such as health-related quality of life and current health state, patient satisfaction can be a valuable assessment of quality. Patient and family satisfaction measures not only affect a patient's clinical course and influence overall patient compliance, but are increasingly used to gauge physician performance and guide reimbursement. The paucity of standardized measures and the subjective nature of patient and family satisfaction impairs a surgeon's ability to internalize this feedback and institute actions to optimize clinical care. This review seeks to identify areas to improve patient and family satisfaction with the perioperative experience.
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Affiliation(s)
- Kristen A Calabro
- Department of Pediatric Surgery, John R. Oishei Children's Hospital, Buffalo, NY, USA; Department of Surgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, USA
| | - Mehul V Raval
- Department of Pediatric Surgery, Children's Healthcare of Atlanta, and Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - David H Rothstein
- Department of Pediatric Surgery, John R. Oishei Children's Hospital, Buffalo, NY, USA; Department of Surgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, USA.
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Short HL, Heiss KF, Burch K, Travers C, Edney J, Venable C, Raval MV. Implementation of an enhanced recovery protocol in pediatric colorectal surgery. J Pediatr Surg 2018; 53:688-692. [PMID: 28545764 DOI: 10.1016/j.jpedsurg.2017.05.004] [Citation(s) in RCA: 83] [Impact Index Per Article: 13.8] [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] [Received: 03/09/2017] [Revised: 05/03/2017] [Accepted: 05/05/2017] [Indexed: 12/20/2022]
Abstract
PURPOSE Enhanced recovery protocols (ERPs) have been shown to improve outcomes in adult surgical populations. Our purpose was to compare outcomes before and after implementation of an ERP in children undergoing elective colorectal surgery. METHODS A pediatric-specific colorectal ERP was developed and implemented at a single center starting in January 2015. A retrospective review was performed including 43 patients in the pre-ERP period (2012-2014) and 36 patients in the post-ERP period (2015-2016). Outcomes of interest included number of ERP interventions received, length of stay (LOS), complications, and readmissions. RESULTS The median number of ERP interventions received per patient increased from 5 to 11 from 2012 to 2016. The median LOS decreased from 5days to 3days in the post-ERP period (p=0.01). We observed a simultaneous decrease in median time to regular diet, mean dose of narcotics, and mean volume of intraoperative fluids (p<0.001). The complication rate (21% vs. 17%, p=0.85) and 30-day readmission rate (23% vs. 11%, p=0.63) were not significantly different in the pre- and post-ERP periods. CONCLUSIONS Implementation of a pediatric-specific ERP in children undergoing colorectal surgery is feasible, safe and may lead to improved outcomes. Further experience may highlight other opportunities for increased compliance and improved care. LEVEL OF EVIDENCE Treatment Study. Level III.
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Affiliation(s)
- Heather L Short
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Kurt F Heiss
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Katelyn Burch
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Curtis Travers
- Division of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - John Edney
- Division of Pediatric Anesthesiology, Department of Anesthesiology, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Claudia Venable
- Division of Pediatric Anesthesiology, Department of Anesthesiology, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Mehul V Raval
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA.
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Abstract
The operating room is the financial hub of any hospital, and maximizing operating room efficiency has important implications for cost savings, patient satisfaction, and medical team morale. Over the past decade, manufacturing principles and processes such as Lean and Six Sigma have been applied to various aspects of healthcare including the operating room. Although time consuming, process mapping and deep examinations of each step of the patient journey from pre-operative visit to post-operative discharge can have multiplicative benefits that extend from cost savings to maintaining the focus on improving quality and patient safety.
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Affiliation(s)
- David H Rothstein
- Department of Pediatric Surgery, John R. Oishei Children's Hospital, and Department of Surgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, United States.
| | - Mehul V Raval
- Department of Pediatric Surgery, Children's Healthcare of Atlanta, and Department of Surgery, Emory University School of Medicine, Atlanta, GA, United States
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124
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Abstract
For over 20 years enhanced recovery protocols (ERPs) have been used to decrease the physiologic stress and inflammation of surgery using evidence-based principles. ERPs include optimizing patient preparation, creating less trauma using minimally invasive anesthetic and surgical techniques, and regular audit of outcomes. A critical aspect of ERPs is patient engagement in all phases of care, which facilitates effective team function and focused oversight of patient flow through the system. Counseling extends beyond traditional review of surgical risks and benefits, by creating clear daily patient goals, establishing pain management plans, optimizing nutrition, and defining criteria for discharge. The patient and family are provided written and visual media resources to review. This counseling and education clearly outlines the bidirectional expectations, ensures preparedness, and empowers the patient and family by explaining the logic surrounding many of the ERP interventions. The patient and family are, in turn, activated as key stakeholders in the process and have a shared vision with the healthcare team. Most patients enjoy being considered partners and agents in their own healthcare. ERPs facilitate an optimal surgical experience that can improve patient satisfaction, outcomes, and value.
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Affiliation(s)
- Kurt F Heiss
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Mehul V Raval
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA, USA.
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125
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Short HL, Taylor N, Piper K, Raval MV. Appropriateness of a pediatric-specific enhanced recovery protocol using a modified Delphi process and multidisciplinary expert panel. J Pediatr Surg 2018; 53:592-598. [PMID: 29017725 DOI: 10.1016/j.jpedsurg.2017.09.008] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Revised: 08/11/2017] [Accepted: 09/16/2017] [Indexed: 12/23/2022]
Abstract
PURPOSE Despite Enhanced Recovery After Surgery (ERAS) protocols demonstrating improved outcomes in a wide variety of adult surgical populations, these protocols are infrequently and inconsistently being used in pediatric surgery. Our purpose was to develop a pediatric-specific ERAS protocol for use in adolescents undergoing elective intestinal procedures. METHODS A modified Delphi process including extensive literature review, iterative rounds of surveys, and expert panel discussions was used to establish ERAS elements that would be appropriate for children. The 16-member multidisciplinary expert panel included surgeons, gastroenterologists, anesthesiologists, nursing, and patient/family representatives. RESULTS Building upon a national survey of surgeons in which 14 of 21 adult ERAS elements were considered acceptable for use in children, the 7 more contentious elements were investigated using the modified Delphi process. In final ranking, 5 of the 7 controversial elements were deemed appropriate for inclusion in a pediatric ERAS protocol. Routine use of insulin to treat hyperglycemia and avoidance of mechanical bowel preparation were not included in the final recommendations. CONCLUSIONS Using a modified Delphi process, we have defined an appropriate ERAS protocol comprised of 19 elements for use in adolescents undergoing elective intestinal surgery. Prospective validation studies of ERAS protocols in children are needed. LEVEL OF EVIDENCE Level V, Expert opinion.
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Affiliation(s)
- Heather L Short
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Natalie Taylor
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Kaitlin Piper
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Mehul V Raval
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA.
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Raval MV, Rothstein DH. Preface. Semin Pediatr Surg 2018; 27:65-66. [PMID: 29548353 DOI: 10.1053/j.sempedsurg.2018.02.001] [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: 11/11/2022]
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127
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Short HL, Taylor N, Thakore M, Piper K, Baxter K, Heiss KF, Raval MV. A survey of pediatric surgeons' practices with enhanced recovery after children's surgery. J Pediatr Surg 2018; 53:418-430. [PMID: 28655398 DOI: 10.1016/j.jpedsurg.2017.06.007] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 05/26/2017] [Accepted: 06/12/2017] [Indexed: 11/18/2022]
Abstract
PURPOSE Enhanced Recovery After Surgery (ERAS) protocols have been shown to improve outcomes in adult abdominal surgical populations. Our purpose was to survey pediatric surgeons' opinions regarding applicability of individual ERAS elements to children's surgery. METHODS A survey of the American Pediatric Surgical Association was conducted electronically. Using a 5-point Likert scale, respondents rated their willingness to implement 21 adult ERAS elements in an adolescent undergoing elective colorectal surgery. RESULTS Of an estimated 1052 members, 257 completed the survey (24%). The majority of the respondents (n=175, 68.4%) rated their familiarity with ERAS as "moderately", "very", or "extremely familiar". However only 19.2% (n=49) replied that they were "already implementing" an ERAS protocol in their practice. Most respondents replied that they were "already doing" or "definitely willing" to implement 14 of the 21 (67%) ERAS elements. For the remaining 7 elements, >10% of surgeons answered that they were only "somewhat willing" to, "uncertain" about or "unwilling" to implement these interventions. CONCLUSIONS Most respondents were willing to implement the majority of adult ERAS concepts in children undergoing abdominal surgery. However, we identified 7 elements that remain contentious. Further investigation regarding the safety and feasibility of these elements is warranted before applying them to children's surgery. LEVEL OF EVIDENCE Level V.
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Affiliation(s)
- Heather L Short
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Natalie Taylor
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Mitali Thakore
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Kaitlin Piper
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Katherine Baxter
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Kurt F Heiss
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Mehul V Raval
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA.
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128
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Abstract
Appendectomy is the most common abdominal surgical procedure performed in children in the United States. In order to assist care providers in creating treatment plans for the postoperative management of pediatric appendicitis, we have developed a predictive statistical model of outcomes on which we have built a prototype decision aid application. The model, trained on 3724 anonymized care records and evaluated on a separate set of 2205 cases from a tertiary care center, achieves 97.0% specificity, 25.1% true sensitivity, and 58.8% precision. We have also built an interactive decision support tool augmented with simple visualization techniques designed for clinicians to use in the course of making care decisions (e.g., discharge) and in patient/stakeholder communication. Its focus is on end-user ease of use and integration into existing clinician workflows, and is designed to evolve its predictions as more and better data become available.
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Affiliation(s)
- Edward Clarkson
- Electro-Optical Systems Lab, Georgia Tech Research Institute, 925 Dalney St., Atlanta, GA, 30332-0834, USA.
| | - Jason Zutty
- Electro-Optical Systems Lab, Georgia Tech Research Institute, 925 Dalney St., Atlanta, GA, 30332-0834, USA
| | - Mehul V Raval
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA, 30322, USA
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129
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Cairo SB, Raval MV, Browne M, Meyers H, Rothstein DH. Association of Same-Day Discharge With Hospital Readmission After Appendectomy in Pediatric Patients. JAMA Surg 2018; 152:1106-1112. [PMID: 28678998 DOI: 10.1001/jamasurg.2017.2221] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Importance Appendectomy is the most common abdominal operation performed in pediatric patients in the United States. Studies in adults have suggested that same-day discharge (SDD) after appendectomy is safe and does not result in higher-than-expected hospital readmissions. Objective To evaluate the influence of SDD on 30-day readmission rates following appendectomy for acute appendicitis in pediatric patients. Design, Setting, and Participants This retrospective cohort study used the American College of Surgeons National Surgical Quality Improvement Program-Pediatric database to evaluate 30-day readmission rates among pediatric patients who underwent an appendectomy for acute, nonperforated appendicitis. The database provides high-quality surgical outcomes data from more than 80 participating US hospitals, including free-standing pediatric facilities, children's hospitals, specialty centers, children's units within adult hospitals, and general acute care hospitals with a pediatric wing. Patients selected for inclusion (n = 22 771) were between ages 0 and 17 years and underwent appendectomy for uncomplicated appendicitis between January 1, 2012, and December 31, 2015. Patients excluded were those discharged more than 2 days after surgery. Exposures Same-day discharge after appendectomy or discharge 1 or 2 days after surgery. Main Outcomes and Measures The primary outcome was 30-day readmission. Secondary outcomes included surgical-site infections and other wound complications. Results Of the 20 981 patients, 4662 (22.2%) had SDD and 16 319 (77.8%) were discharged within 1 or 2 days after surgery. The patient cohort included 12 860 boys (61.3%) and 8121 girls (38.7%), with a mean (SD) age of 11.0 (3.56) years. There was no difference in the odds of readmission for patients with SDD compared with those discharged within 2 days (adjusted odds ratio [aOR], 0.82; 95% CI, 0.51-1.04; P = .06; readmission rate, 1.89% vs 2.33%). There was no significant difference in reason for readmission on the basis of discharge timing. Likewise, there was no difference in wound complication rate between patients with SDD and those discharged 1 or 2 days after surgery (aOR 0.75; 95% CI, 0.56-1.01; P = .06). Conclusions and Relevance In pediatric patients with acute appendicitis undergoing appendectomy, SDD is not associated with an increase in 30-day hospital readmission rates or wound complications when compared with discharge 1 or 2 days after surgery. Same-day discharge may be an applicable quality metric for the provision of safe and efficient care for pediatric patients with acute, nonperforated appendicitis.
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Affiliation(s)
- Sarah B Cairo
- Pediatric Surgery, Women and Children's Hospital of Buffalo, Buffalo, New York
| | - Mehul V Raval
- Department of Pediatric Surgery, Children's Healthcare of Atlanta, Atlanta, Georgia.,Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Marybeth Browne
- Department of Pediatric Surgery, Lehigh Valley Children's Hospital, Allentown, Pennsylvania
| | - Holly Meyers
- Pediatric Surgery, Women and Children's Hospital of Buffalo, Buffalo, New York
| | - David H Rothstein
- Pediatric Surgery, Women and Children's Hospital of Buffalo, Buffalo, New York.,Department of Surgery, University at Buffalo, Buffalo, New York
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130
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Bhatt D, Travers C, Patel RM, Shinnick J, Arps K, Keene S, Raval MV. Predicting Mortality or Intestinal Failure in Infants with Surgical Necrotizing Enterocolitis. J Pediatr 2017; 191:22-27.e3. [PMID: 29173311 PMCID: PMC5871227 DOI: 10.1016/j.jpeds.2017.08.046] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [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: 04/28/2017] [Revised: 07/18/2017] [Accepted: 08/17/2017] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To compare existing outcome prediction models and create a novel model to predict death or intestinal failure (IF) in infants with surgical necrotizing enterocolitis (NEC). STUDY DESIGN A retrospective, observational cohort study conducted in a 2-campus health system in Atlanta, Georgia, from September 2009 to May 2015. Participants included all infants ≤37 weeks of gestation with surgical NEC. Logistic regression was used to model the probability of death or IF, as a composite outcome, using preoperative variables defined by specifications from 3 existing prediction models: American College of Surgeons National Surgical Quality Improvement Program Pediatric, Score for Neonatal Acute Physiology Perinatal Extension, and Vermont Oxford Risk Adjustment Tool. A novel preoperative hybrid prediction model was also derived and validated against a patient cohort from a separate campus. RESULTS Among 147 patients with surgical NEC, discrimination in predicting death or IF was greatest with American College of Surgeons National Surgical Quality Improvement Program Pediatric (area under the receiver operating characteristic curve [AUC], 0.84; 95% CI, 0.77-0.91) when compared with the Score for Neonatal Acute Physiology Perinatal Extension II (AUC, 0.60; 95% CI, 0.48-0.72) and Vermont Oxford Risk Adjustment Tool (AUC, 0.74; 95% CI, 0.65-0.83). A hybrid model was developed using 4 preoperative variables: the 1-minute Apgar score, inotrope use, mean blood pressure, and sepsis. The hybrid model AUC was 0.85 (95% CI, 0.78-0.92) in the derivation cohort and 0.77 (95% CI, 0.66-0.86) in the validation cohort. CONCLUSIONS Preoperative prediction of death or IF among infants with surgical NEC is possible using existing prediction tools and, to a greater extent, using a newly proposed 4-variable hybrid model.
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Affiliation(s)
- Darshna Bhatt
- Division of Neonatology, Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA.
| | - Curtis Travers
- Biostatisitcal Core, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Ravi M. Patel
- Division of Neonatology, Department of Pediatrics, Emory University School of Medicine, Children’s Healthcare of Atlanta, Atlanta, GA, USA
| | - Julia Shinnick
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children’s Healthcare of Atlanta, Atlanta, GA, USA
| | - Kelly Arps
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children’s Healthcare of Atlanta, Atlanta, GA, USA
| | - Sarah Keene
- Division of Neonatology, Department of Pediatrics, Emory University School of Medicine, Children’s Healthcare of Atlanta, Atlanta, GA, USA
| | - Mehul V. Raval
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children’s Healthcare of Atlanta, Atlanta, GA, USA
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131
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Gutierrez CA, Raval MV, Vester HR, Chaudhury S, von Allmen D, Rothstein DH. Surgical treatment of intestinal complications of graft versus host disease in the pediatric population: Case series and review of literature. J Pediatr Surg 2017; 52:1718-1722. [PMID: 28711168 DOI: 10.1016/j.jpedsurg.2017.06.022] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [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: 12/26/2016] [Revised: 05/22/2017] [Accepted: 06/23/2017] [Indexed: 01/06/2023]
Abstract
BACKGROUND/PURPOSE Intestinal complications of acute graft-versus-host disease (aGVHD) include hemorrhage and perforation in the short-term, and stricture with bowel obstruction in the long-term. As medical management of severe aGVHD has improved, more patients are surviving even advanced stages of intestinal aGVHD. This review summarizes the available pediatric literature on surgical treatment of complications of intestinal GVHD. METHODS A systematic review was performed using PubMed, Cochrane, Embase, and Scopus databases. Any publication that addressed surgical treatment of acute and chronic intestinal GVHD in the pediatric population was reviewed in detail. Furthermore, we included information on 5 additional patients from the institutions of this review's authors, which had not been previously published. RESULTS We identified 8 studies, comprising 13 patients. Surgical interventions were undertaken for a variety of intestinal GVHD complications, including small bowel obstruction owing to stricture (n=8), enterocutaneous fistulae (n=2), gastrointestinal hemorrhage/perforation (n=1 each), and esophageal stricture (n=1). Among eight patients with bowel obstruction as an indication, pathology revealed ulceration with fibrosis in all but one; 3 had signs of persistent GVHD. Surgical mortality was reported in 4 patients (31%) at an average of 6weeks postoperatively. The median overall follow-up time was 20months (IQR, 2-21). CONCLUSIONS Although intestinal aGVHD management is almost exclusively medical, a small subset of patients develops complications of intestinal GVHD that require surgical intervention. With expanding indications for stem cell transplantation as well as improved survival after previously fatal bouts of intestinal aGVHD, it is likely that surgical intervention will become more common in these complicated patients. SYSTEMATIC REVIEW Level of Evidence: Level IV.
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Affiliation(s)
- Camille A Gutierrez
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY
| | - Mehul V Raval
- Division of Pediatric Surgery, Department of Surgery, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA
| | - Hannah R Vester
- Division of General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Sonali Chaudhury
- Division of Hematology, Oncology and Stem Cell Transplantation, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago
| | - Daniel von Allmen
- Division of General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - David H Rothstein
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY; Department of Pediatric Surgery, Women and Children's Hospital of Buffalo, Buffalo, NY.
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Baxter KJ, Aiello AC, Raval MV. Effect of Formal Pediatric Sub-Specialization on Surgical Outcomes in Children's Surgery. J Am Coll Surg 2017. [DOI: 10.1016/j.jamcollsurg.2017.07.355] [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: 10/18/2022]
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Baxter KJ, Gale B, Raval MV. Ramifications of the Children's Surgery Verification Program for Patients and Hospitals. J Am Coll Surg 2017. [DOI: 10.1016/j.jamcollsurg.2017.07.278] [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: 11/25/2022]
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Sarda S, Short HL, Hockenberry JM, McCarthy I, Raval MV. Regional variation in rates of pediatric perforated appendicitis. J Pediatr Surg 2017; 52:1488-1491. [PMID: 28259382 DOI: 10.1016/j.jpedsurg.2017.02.009] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Revised: 02/09/2017] [Accepted: 02/11/2017] [Indexed: 11/20/2022]
Abstract
BACKGROUND While trends in perforated appendicitis (PA) rates have been studied, regional variability in pediatric admissions for PA remains unknown. METHODS A retrospective, cross-sectional analysis of the 2006-2012 Kids' Inpatient Database was conducted to examine variation in PA admission rates by region of the United States and insurance status. PA rates were calculated and reported as per 1000 admissions in accordance with national quality measure specifications. RESULTS National PA rates per 1000 admissions for 2006, 2009, and 2012 were 313.9, 279.2, and 309.1, respectively. Similarly, all regions demonstrated a statistically significant decrease in PA rates between 2006 and 2009 (p<0.001), where the increase in rates between 2009 and 2012 was only statistically significant in the Midwest [Odds Ratio (OR) 1.07; 95% Confidence Interval (95%CI) 1.03-1.12] and West (OR 1.10; 95% CI 1.07-1.14). The Northeast consistently experienced the lowest PA rates. The odds of PA were highest among uninsured patients (OR 1.35; 95% CI 1.31-1.29). The South had the highest proportion of uninsured children, and these patients had the highest odds of perforation (OR 1.57; 95% CI 1.21-2.02). CONCLUSIONS For children with appendicitis, geographic region and insurance status appear to be associated with perforation upon presentation. Understanding regional variation in pediatric PA rates may inform health policymakers in the constantly evolving insurance coverage landscape. LEVELS OF EVIDENCE RATING Level III Treatment Study - Retrospective comparative study of appendicitis presentation in children by region of the country.
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Affiliation(s)
- Samir Sarda
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Heather L Short
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Jason M Hockenberry
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Ian McCarthy
- Deparment of Economics, Emory University, Atlanta, GA, USA
| | - Mehul V Raval
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA.
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Baxter KJ, Short HL, Thakore MA, Fisher JG, Rothstein DH, Heiss KF, Raval MV. Cost comparison of initial lobectomy versus fine-needle aspiration for diagnostic workup of thyroid nodules in children. J Pediatr Surg 2017; 52:1471-1474. [PMID: 28073489 DOI: 10.1016/j.jpedsurg.2016.12.021] [Citation(s) in RCA: 2] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Revised: 12/13/2016] [Accepted: 12/26/2016] [Indexed: 01/21/2023]
Abstract
BACKGROUND Though uncommon in children, pediatric thyroid nodules carry a higher risk of malignancy than adult nodules. While fine-needle aspiration (FNA) has been well established as the initial diagnostic test in adults, it has been more slowly adopted in children. The purpose of this study was to examine the comparative cost of FNA versus initial diagnostic lobectomy (DL) in the pediatric patient with an ultrasound-confirmed thyroid nodule. METHODS A decision tree model was created using an adolescent with an asymptomatic thyroid nodule as the reference case. Probabilities were defined based on review of the pediatric and adult literature. Costs were determined from previous literature and the publicly available Medicare physician fee schedule. Tornado plot and sensitivity analyses were performed to assess sources of cost variation. RESULTS Using decision analysis, FNA was less costly than DL with an estimated cost of $2529 vs. $5680. Tornado analysis demonstrated that the probability of an initial indeterminate FNA result contributed most to cost variation. On sensitivity analysis, when probability of an indeterminate FNA result was increased to 35%, the maximum value found in the literature, FNA remained less costly. In Monte Carlo simulation set to 10,000 iterations, FNA was superior to DL in 74% of cases. CONCLUSIONS In this theoretical model based on available literature and costs, FNA is less costly than DL for initial diagnostic workup of thyroid nodules in children. Securing resources to offer FNA in the work-up of thyroid nodules may be financially beneficial to hospitals and patients. LEVEL OF EVIDENCE Level 1 cost effectiveness study - using reasonable costs and alternatives used in study with values obtained from many studies, study used multi-way sensitivity analysis.
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Affiliation(s)
- Katherine J Baxter
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine Children's Healthcare of Atlanta, Atlanta, GA, United States
| | - Heather L Short
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine Children's Healthcare of Atlanta, Atlanta, GA, United States
| | - Mitali A Thakore
- Rollins School of Public Health, Emory University, Atlanta, GA, United States
| | - Jeremy G Fisher
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine Children's Healthcare of Atlanta, Atlanta, GA, United States
| | - David H Rothstein
- Department of Pediatric Surgery, Women and Children's Hospital of Buffalo; Department of Surgery, University at Buffalo, State University of New York, Buffalo, NY, USA
| | - Kurt F Heiss
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine Children's Healthcare of Atlanta, Atlanta, GA, United States
| | - Mehul V Raval
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine Children's Healthcare of Atlanta, Atlanta, GA, United States.
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136
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Partain KN, Patel AU, Travers C, Short HL, Braithwaite K, Loewen J, Heiss KF, Raval MV. Improving ultrasound for appendicitis through standardized reporting of secondary signs. J Pediatr Surg 2017; 52:1273-1279. [PMID: 27939802 PMCID: PMC5459678 DOI: 10.1016/j.jpedsurg.2016.11.045] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [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: 08/17/2016] [Revised: 11/21/2016] [Accepted: 11/28/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Our aim was to implement a standardized US report that included secondary signs of appendicitis (SS) to facilitate accurate diagnosis of appendicitis and decrease the use of computed tomography (CT) and admissions for observation. METHODS A multidisciplinary team implemented a quality improvement (QI) intervention in the form of a standardized US report and provided stakeholders with monthly feedback. Outcomes including report compliance, CT use, and observation admissions were compared pretemplate and posttemplate. RESULTS We identified 387 patients in the pretemplate period and 483 patients in the posttemplate period. In the posttemplate period, the reporting of SS increased from 5.4% to 79.5% (p<0.001). Despite lower rates of appendix visualization (43.9% to 32.7%, p<0.001) with US, overall CT use (8.5% vs 7.0%, p=0.41) and the negative appendectomy rate remained stable (1.0% vs 1.0%, p=1.0). CT utilization for patients with an equivocal ultrasound and SS present decreased (36.4% vs 8.9%, p=0.002) and admissions for observations decreased (21.5% vs 15.3%, p=0.02). Test characteristics of RLQ US for appendicitis also improved in the posttemplate period. CONCLUSION A focused QI initiative led to high compliance rates of utilizing the standardized US report and resulted in lower CT use and fewer admissions for observation. Study of a Diagnostic Test Level of Evidence: 1.
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Affiliation(s)
- Kristin N Partain
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Adarsh U Patel
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Curtis Travers
- Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Heather L Short
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Kiery Braithwaite
- Division of Pediatric Radiology, Department of Radiology and Imaging Services, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Jonathan Loewen
- Division of Pediatric Radiology, Department of Radiology and Imaging Services, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Kurt F Heiss
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Mehul V Raval
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA.
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Abstract
BACKGROUND Despite the availability of objective tests, gastroesophageal reflux disease (GERD) diagnosis and management in infants remains controversial and highly variable. Our purpose was to characterize national variation in diagnostic testing and surgical utilization for infants with GERD. METHODS Using the Pediatric Health Information System, we identified infants <1 year old diagnosed with GERD between January 2011 and March 2015. Outcomes included progression to antireflux surgery (ARS) and use of relevant diagnostic testing. By using adjusted generalized linear mixed models, we compared facility-level ARS utilization. RESULTS Of 5 299 943 infants, 149 190 had GERD (2.9%), and 4518 (3.0%) of those patients underwent ARS. Although annual rates of GERD and ARS decreased, there was a wide range of GERD diagnoses (1.8%-6.2%) and utilization of ARS (0.2%-11.2%). Facilities varied in the use of laparoscopic versus open ARS (mean: 66%, range: 23%-97%). Variation in facility-level ARS rates persisted after adjustment. Overall 3.8% of patients underwent diagnostic testing, whereas 22.8% of ARS patients underwent diagnostic testing. The proportion of surgeries done laparoscopically was independently associated with ARS utilization (odds ratio: 1.57; 95% confidence interval: 1.21-2.02). Facility-level utilization of diagnostics (P > .1) and prevalence of GERD (P > .1) were not associated with utilization of ARS. CONCLUSIONS There is notable variation in the overall utilization of ARS and in the surgical and diagnostic approach in infants with GERD. Fewer than 4% of infants with GERD undergo diagnostic testing. This variation in care merits development of consensus guidelines and further research.
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Affiliation(s)
- Heather L Short
- Division of Pediatric Surgery, Department of Surgery, School of Medicine, Emory University, Atlanta, Georgia; and
| | - Nikolay P Braykov
- Department of Outcomes and Quality Measurement, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - James E Bost
- Department of Outcomes and Quality Measurement, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Mehul V Raval
- Division of Pediatric Surgery, Department of Surgery, School of Medicine, Emory University, Atlanta, Georgia; and
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Short HL, Parakati I, Heiss KF, Wulkan ML, Sweeney JF, Raval MV. Challenge of balancing duration of stay and readmissions in children's operation. Surgery 2017; 162:950-957. [PMID: 28709646 DOI: 10.1016/j.surg.2017.06.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Revised: 06/08/2017] [Accepted: 06/08/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Surgeons balance competing interests of minimizing duration of stay with readmissions. Complications that occur early after discharge often result in readmissions. This study examines the relationship between duration of stay, timing of complications, and readmission risk. METHODS Cases from the 2012-2014 National Surgical Quality Improvement Project-Pediatric were organized into 30 procedural groups. Procedures where duration of stay approximated the median day of complication were identified. A theoretical model was applied to minimize readmissions by extending duration of stay. RESULTS From 30 procedure groups, 3 were identified where duration of stay approximated median day of compilations: complicated appendectomy, antireflux operation, and abdominal operation without bowel resection. The complicated appendectomy readmission rate drops from 12.2% to 8.2%, increasing duration of stay from 3 to 8 days at the cost of 16,428 additional hospital days among 4,740 patients (3.5 days/patient). Readmission optimization tapers after duration of stay of 8 days. Similar findings were observed for antireflux operation and abdominal operation without bowel resection with readmission optimization at duration of stay of 5 days (2.6 days/patient) and 7 days (5.3 days/patient), respectively. CONCLUSION Our theoretical model aimed at balancing readmissions by extending duration of stay to capture early complications results in a substantial increase in hospital days illustrating the conflict between competing quality metrics and limited resources.
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Affiliation(s)
- Heather L Short
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA
| | - Isaac Parakati
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA
| | - Kurt F Heiss
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA
| | - Mark L Wulkan
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA
| | - John F Sweeney
- Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | - Mehul V Raval
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA.
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Garner EF, Maizlin II, Dellinger MB, Gow KW, Goldfarb M, Goldin AB, Doski JJ, Langer M, Nuchtern JG, Vasudevan SA, Raval MV, Beierle EA. Effects of socioeconomic status on children with well-differentiated thyroid cancer. Surgery 2017; 162:662-669. [PMID: 28602495 DOI: 10.1016/j.surg.2017.04.008] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Revised: 04/10/2017] [Accepted: 04/11/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND Well-differentiated thyroid cancer is the most common endocrine malignancy in children. Adult literature has demonstrated socioeconomic disparities in patients undergoing thyroidectomy, but the effects of socioeconomic status on the management of pediatric well-differentiated thyroid cancer remains poorly understood. METHODS Patients ≤21 years of age with well-differentiated thyroid cancer remains were reviewed from the National Cancer Data Base. Three socioeconomic surrogate variables were identified: insurance type, median income, and educational quartile. Tumor characteristics, diagnostic intervals, and clinical outcomes were compared within each socioeconomic surrogate variable. RESULTS A total of 9,585 children with well-differentiated thyroid cancer remains were reviewed. In multivariate analysis, lower income, lower educational quartile, and insurance status were associated with higher stage at diagnosis. Furthermore, lower income quartile was associated with a longer time from diagnosis to treatment (P < .002). Similarly, uninsured children had a longer time from diagnosis to treatment (28 days) compared with those with government (19 days) or private (18 days) insurance (P < .001). Despite being diagnosed at a higher stage and having a longer time interval between diagnosis and treatment, there was no significant difference in either overall survival or rates of unplanned readmissions based on any of the socioeconomic surrogate variables. CONCLUSION Children from lower income families and those lacking insurance experienced a longer period from diagnosis to treatment of their well-differentiated thyroid cancer remains. These patients also presented with higher stage disease. These data suggest a delay in care for children from low-income families. Although these findings did not translate into worse outcomes for well-differentiated thyroid cancer remains, future efforts should focus on reducing these differences.
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Affiliation(s)
- Evan F Garner
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Ilan I Maizlin
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Matthew B Dellinger
- Division of Pediatric General and Thoracic Surgery, Seattle Children's Hospital, Seattle, WA
| | - Kenneth W Gow
- Division of Pediatric General and Thoracic Surgery, Seattle Children's Hospital, Seattle, WA
| | - Melanie Goldfarb
- Department of Surgery, John Wayne Cancer Institute at Providence St. John's Health Center, Santa Monica, CA
| | - Adam B Goldin
- Division of Pediatric General and Thoracic Surgery, Seattle Children's Hospital, Seattle, WA
| | - John J Doski
- Department of Surgery, Methodist Children's Hospital of South Texas, University of Texas Health Science Center-San Antonio, San Antonio, TX
| | - Monica Langer
- Department of Surgery, Maine Children's Cancer Program, Tufts University, Portland, ME
| | - Jed G Nuchtern
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Sanjeev A Vasudevan
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Mehul V Raval
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA
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Short HL, Travers C, McCracken C, Wulkan ML, Clifton MS, Raval MV. Increased morbidity and mortality in cardiac patients undergoing fundoplication. Pediatr Surg Int 2017; 33:559-567. [PMID: 28039511 DOI: 10.1007/s00383-016-4033-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [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] [Accepted: 12/05/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND Infants with congenital cardiac disease (CCD) often require gastrostomy tube placement (GT) and need antireflux procedures, such as fundoplications. Our purpose was to compare morbidity/mortality rates among infants with CCD undergoing GT, fundoplication, or both. METHODS Using the NSQIP-Pediatric, we identified 4070 patients <1-year-old who underwent GT and/or fundoplication from 2012 to 2014. 2346 infants (58%) had CCD categorized as minor, major or severe. Regression models were used to estimate the association of CCD with morbidity/mortality. RESULTS Among all patients undergoing fundoplication, there were increased odds of morbidity/mortality among CCD patients compared to non-CCD patients (OR 2.15; p < 0.001). Odds of complications decreased when procedures were performed laparoscopically or later in the first year of life. Using GT alone as a reference, fundoplication alone (OR 1.67; p < 0.001) and GT with fundoplication (OR 1.82; p < 0.001) had increased odds of morbidity/mortality among cardiac patients. Increased risk persisted after stratification by severity of CCD and after accounting for surgical approach. CONCLUSION Fundoplication is associated with increased odds of morbidity/mortality in infants with CCD compared to GT alone. Risks are lower with laparoscopic approach and if surgery is delayed until later in the first year of life. Timing and surgical approach for patients with CCD requires further investigation.
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Affiliation(s)
- Heather L Short
- Division of Pediatric Surgery, Department of Surgery, Children's Healthcare of Atlanta, Emory University School of Medicine, 1405 Clifton Road NE, Atlanta, GA, 30322, USA
| | - Curtis Travers
- Division of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Courtney McCracken
- Division of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Mark L Wulkan
- Division of Pediatric Surgery, Department of Surgery, Children's Healthcare of Atlanta, Emory University School of Medicine, 1405 Clifton Road NE, Atlanta, GA, 30322, USA
| | - Matthew S Clifton
- Division of Pediatric Surgery, Department of Surgery, Children's Healthcare of Atlanta, Emory University School of Medicine, 1405 Clifton Road NE, Atlanta, GA, 30322, USA
| | - Mehul V Raval
- Division of Pediatric Surgery, Department of Surgery, Children's Healthcare of Atlanta, Emory University School of Medicine, 1405 Clifton Road NE, Atlanta, GA, 30322, USA.
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Abstract
BACKGROUND There is significant variation surrounding the indications, surgical approaches, and outcomes for children undergoing antireflux procedures (ARPs) resulting in geographic variation of care. Our purpose was to quantify this geographic variation in the utilization of ARPs in children. METHODS A cross-sectional analysis of the 2009 Kid's Inpatient Database was performed to identify patients with gastroesophageal reflux disease or associated diagnoses. Regional surgical utilization rates were determined, and a mixed effects model was used to identify factors associated with the use of ARPs. RESULTS Of the 148,959 patients with a diagnosis of interest, 4848 (3.3%) underwent an ARP with 2376 (49%) undergoing a laparoscopic procedure. The Northeast (2.0%) and Midwest (2.2%) had the lowest overall utilization of surgery, compared with the South (3.3%) and West (3.4%). After adjustment for age, case-mix, and surgical approach, variation persisted with the West and the South demonstrating almost two times the odds of undergoing an ARP compared with the Northeast. Surgical utilization rates are independent of state-level volume with some of the highest case volume states having surgical utilization rates below the national rate. In the West, the use of laparoscopy correlated with overall utilization of surgery, whereas surgical approach was not correlated with ARP use in the South. CONCLUSIONS Significant regional variation in ARP utilization exists that cannot be explained entirely by differences in patient age, race/ethnicity, case-mix, and surgical approach. In order to decrease variation in care, further research is warranted to establish consensus guidelines regarding indications for the use ARPs for children.
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Affiliation(s)
- Heather L Short
- Division of Pediatric Surgery, Department of Surgery, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia
| | - Wanzhe Zhu
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University School of Medicine, Atlanta, Georgia
| | - Courtney McCracken
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Curtis Travers
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Lance A Waller
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University School of Medicine, Atlanta, Georgia
| | - Mehul V Raval
- Division of Pediatric Surgery, Department of Surgery, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia.
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Berman L, Hronek C, Raval MV, Browne ML, Snyder CL, Heiss KF, Rangel SJ, Goldin AB, Rothstein DH. Pediatric Gastrostomy Tube Placement: Lessons Learned from High-performing Institutions through Structured Interviews. Pediatr Qual Saf 2017; 2:e016. [PMID: 30229155 PMCID: PMC6132912 DOI: 10.1097/pq9.0000000000000016] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [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: 08/22/2015] [Accepted: 01/12/2016] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Gastrostomy tube (GT) placement is one of the most common operations performed in children, and it is plagued by high complication rates. Previous studies have shown variation in readmission and emergency room visit rates across different children's hospitals, with both low and high outliers. There is an opportunity to learn how to optimize outcomes by identifying practices at high-performing institutions. METHODS Surgeons and nurses routinely involved in GT care at 8 high-performing pediatric centers were identified. We conducted structured interviews focusing on the approach to GT education, technical aspects of GT placement, and postoperative management. Summary statistics were performed on quantitative data, and the open-ended responses were analyzed by 2 independent reviewers using content analysis. RESULTS Several common practices among high-performing centers were identified (standardized approach to education, availability by phone and in clinic to manage GT-related issues, and empowering families to feel confident with troubleshooting and dealing with GT problems). There was substantial variation in operative technique and postoperative care. The participants expressed that technical aspects of operative placement and postoperative management of feedings and common complications are not as important as education, availability, and empowerment in optimizing outcomes. CONCLUSIONS We have identified common themes among pediatric centers with favorable outcomes after GT placement. Identifying which components of GT care are associated with optimal outcomes is critical to our understanding of current practice and may help identify opportunities to improve care quality.
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Affiliation(s)
- Loren Berman
- From the Nemours-A.I. duPont Hospital for Children, Wilmington, Dle.; Sidney Kimmel College of Medicine, Philadelphia, Pa.; Children’s Hospital Association, Overland Park, Kans.; Emory University, Children’s Healthcare of Atlanta, Atlanta, Ga.; Lehigh Valley Children’s Hospital, Morsani College of Medicine, University of South Florida, Allentown, Pa.; Children’s Mercy Hospital, Kansas City, Mo.; Boston Children’s Hospital, Harvard Medical School, Boston, Mass.; Department of Pediatric General and Thoracic Surgery, Seattle Children’s Hospital, Seattle, Wash.; University of Washington School of Medicine, Seattle, Wash.; Department of Pediatric Surgery, Women and Children’s Hospital of Buffalo, Buffalo, N.Y.; and Department of Surgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, N.Y
| | - Carla Hronek
- From the Nemours-A.I. duPont Hospital for Children, Wilmington, Dle.; Sidney Kimmel College of Medicine, Philadelphia, Pa.; Children’s Hospital Association, Overland Park, Kans.; Emory University, Children’s Healthcare of Atlanta, Atlanta, Ga.; Lehigh Valley Children’s Hospital, Morsani College of Medicine, University of South Florida, Allentown, Pa.; Children’s Mercy Hospital, Kansas City, Mo.; Boston Children’s Hospital, Harvard Medical School, Boston, Mass.; Department of Pediatric General and Thoracic Surgery, Seattle Children’s Hospital, Seattle, Wash.; University of Washington School of Medicine, Seattle, Wash.; Department of Pediatric Surgery, Women and Children’s Hospital of Buffalo, Buffalo, N.Y.; and Department of Surgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, N.Y
| | - Mehul V. Raval
- From the Nemours-A.I. duPont Hospital for Children, Wilmington, Dle.; Sidney Kimmel College of Medicine, Philadelphia, Pa.; Children’s Hospital Association, Overland Park, Kans.; Emory University, Children’s Healthcare of Atlanta, Atlanta, Ga.; Lehigh Valley Children’s Hospital, Morsani College of Medicine, University of South Florida, Allentown, Pa.; Children’s Mercy Hospital, Kansas City, Mo.; Boston Children’s Hospital, Harvard Medical School, Boston, Mass.; Department of Pediatric General and Thoracic Surgery, Seattle Children’s Hospital, Seattle, Wash.; University of Washington School of Medicine, Seattle, Wash.; Department of Pediatric Surgery, Women and Children’s Hospital of Buffalo, Buffalo, N.Y.; and Department of Surgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, N.Y
| | - Marybeth L. Browne
- From the Nemours-A.I. duPont Hospital for Children, Wilmington, Dle.; Sidney Kimmel College of Medicine, Philadelphia, Pa.; Children’s Hospital Association, Overland Park, Kans.; Emory University, Children’s Healthcare of Atlanta, Atlanta, Ga.; Lehigh Valley Children’s Hospital, Morsani College of Medicine, University of South Florida, Allentown, Pa.; Children’s Mercy Hospital, Kansas City, Mo.; Boston Children’s Hospital, Harvard Medical School, Boston, Mass.; Department of Pediatric General and Thoracic Surgery, Seattle Children’s Hospital, Seattle, Wash.; University of Washington School of Medicine, Seattle, Wash.; Department of Pediatric Surgery, Women and Children’s Hospital of Buffalo, Buffalo, N.Y.; and Department of Surgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, N.Y
| | - Charles L. Snyder
- From the Nemours-A.I. duPont Hospital for Children, Wilmington, Dle.; Sidney Kimmel College of Medicine, Philadelphia, Pa.; Children’s Hospital Association, Overland Park, Kans.; Emory University, Children’s Healthcare of Atlanta, Atlanta, Ga.; Lehigh Valley Children’s Hospital, Morsani College of Medicine, University of South Florida, Allentown, Pa.; Children’s Mercy Hospital, Kansas City, Mo.; Boston Children’s Hospital, Harvard Medical School, Boston, Mass.; Department of Pediatric General and Thoracic Surgery, Seattle Children’s Hospital, Seattle, Wash.; University of Washington School of Medicine, Seattle, Wash.; Department of Pediatric Surgery, Women and Children’s Hospital of Buffalo, Buffalo, N.Y.; and Department of Surgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, N.Y
| | - Kurt F. Heiss
- From the Nemours-A.I. duPont Hospital for Children, Wilmington, Dle.; Sidney Kimmel College of Medicine, Philadelphia, Pa.; Children’s Hospital Association, Overland Park, Kans.; Emory University, Children’s Healthcare of Atlanta, Atlanta, Ga.; Lehigh Valley Children’s Hospital, Morsani College of Medicine, University of South Florida, Allentown, Pa.; Children’s Mercy Hospital, Kansas City, Mo.; Boston Children’s Hospital, Harvard Medical School, Boston, Mass.; Department of Pediatric General and Thoracic Surgery, Seattle Children’s Hospital, Seattle, Wash.; University of Washington School of Medicine, Seattle, Wash.; Department of Pediatric Surgery, Women and Children’s Hospital of Buffalo, Buffalo, N.Y.; and Department of Surgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, N.Y
| | - Shawn J. Rangel
- From the Nemours-A.I. duPont Hospital for Children, Wilmington, Dle.; Sidney Kimmel College of Medicine, Philadelphia, Pa.; Children’s Hospital Association, Overland Park, Kans.; Emory University, Children’s Healthcare of Atlanta, Atlanta, Ga.; Lehigh Valley Children’s Hospital, Morsani College of Medicine, University of South Florida, Allentown, Pa.; Children’s Mercy Hospital, Kansas City, Mo.; Boston Children’s Hospital, Harvard Medical School, Boston, Mass.; Department of Pediatric General and Thoracic Surgery, Seattle Children’s Hospital, Seattle, Wash.; University of Washington School of Medicine, Seattle, Wash.; Department of Pediatric Surgery, Women and Children’s Hospital of Buffalo, Buffalo, N.Y.; and Department of Surgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, N.Y
| | - Adam B. Goldin
- From the Nemours-A.I. duPont Hospital for Children, Wilmington, Dle.; Sidney Kimmel College of Medicine, Philadelphia, Pa.; Children’s Hospital Association, Overland Park, Kans.; Emory University, Children’s Healthcare of Atlanta, Atlanta, Ga.; Lehigh Valley Children’s Hospital, Morsani College of Medicine, University of South Florida, Allentown, Pa.; Children’s Mercy Hospital, Kansas City, Mo.; Boston Children’s Hospital, Harvard Medical School, Boston, Mass.; Department of Pediatric General and Thoracic Surgery, Seattle Children’s Hospital, Seattle, Wash.; University of Washington School of Medicine, Seattle, Wash.; Department of Pediatric Surgery, Women and Children’s Hospital of Buffalo, Buffalo, N.Y.; and Department of Surgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, N.Y
| | - David H. Rothstein
- From the Nemours-A.I. duPont Hospital for Children, Wilmington, Dle.; Sidney Kimmel College of Medicine, Philadelphia, Pa.; Children’s Hospital Association, Overland Park, Kans.; Emory University, Children’s Healthcare of Atlanta, Atlanta, Ga.; Lehigh Valley Children’s Hospital, Morsani College of Medicine, University of South Florida, Allentown, Pa.; Children’s Mercy Hospital, Kansas City, Mo.; Boston Children’s Hospital, Harvard Medical School, Boston, Mass.; Department of Pediatric General and Thoracic Surgery, Seattle Children’s Hospital, Seattle, Wash.; University of Washington School of Medicine, Seattle, Wash.; Department of Pediatric Surgery, Women and Children’s Hospital of Buffalo, Buffalo, N.Y.; and Department of Surgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, N.Y
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Short HL, Heiss KF, Wulkan ML, Raval MV. Clinical validity and relevance of accidental puncture or laceration as a patient safety indicator for children. J Pediatr Surg 2017; 52:172-176. [PMID: 27842957 DOI: 10.1016/j.jpedsurg.2016.10.043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Accepted: 10/20/2016] [Indexed: 11/18/2022]
Abstract
PURPOSE Accidental puncture or laceration (APL) has been endorsed as a patient safety indicator and is being used to compare hospital performance and for reimbursement. We sought to determine the positive predictive value (PPV) of APL as a quality metric in a pediatric population. METHODS We retrospectively reviewed all cases that met APL administrative criteria over 5years in a quaternary pediatric hospital system. Events were categorized as false positive (FP) or true positive (TP). TP cases were further categorized as "potentially consequential" or "inconsequential". The PPV of APL was calculated, and a z-test was used to provide 95% confidence intervals. RESULTS Of the 238 cases identified, 204 were categorized as TP (86%; 95% CI: 80%-90%). Thirty-four of these events (17%) involved injuries that were considered "inconsequential". True events that required repair were identified as "potentially consequential" (n=170). Thus, the PPV of APL was 71% (95% CI: 65%-77%). Extenuating factors such as adhesive disease or abnormal anatomy were present in 39% of TP cases. Thirty-four cases (14%) were categorized as FP because no documented injury was found. CONCLUSIONS A large proportion of APL events are either false or clinically irrelevant, thus questioning its usability as a patient safety indicator for children undergoing surgery. TYPE OF STUDY Retrospective review. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Heather L Short
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA
| | - Kurt F Heiss
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA
| | - Mark L Wulkan
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA
| | - Mehul V Raval
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA.
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Abstract
Objective Outcomes for gastroschisis (GS) remain highly variable and avoiding infectious complications (ICs) may represent a significant improvement opportunity. Our objective was to provide estimates of the impact of IC on length of stay (LOS) and costs. Study Design Using a national database, 1,378 patients with GS were identified. Patient and hospital characteristics were compared and LOS and costs evaluated for patients with and without IC. Results Two-thirds of all GS patients had IC, and IC were common for simple and complex GS (65, 73%, respectively). After controlling for patient and hospital factors, LOS in patients with IC was significantly longer than in patients without IC (4.5-day increase, p = 0.001). Specifically, sepsis was associated with increasing median LOS by 11 days (p ≤ 0.001), candida infection by 14 days (p < 0.001), and wound infection by 7 days (p = 0.007). Although overall costs did not differ between patients with and without IC, costs were elevated based on specific IC. Sepsis increased median costs by $22,380 (95% confidence interval [CI]: $14,372-30,388; p ≤ 0.001), wound infection by $32,351 (95% CI: $17,221-47,481; p ≤ 0.001), catheter-related infection by $57,180 (95% CI: $12,834-101,527; p = 0.011), and candida infections by $24,500 (95% CI: $8,832-40,167; p = 0.002). Conclusion IC among GS patients are common and contribute to increased LOS and costs. Quantifying clinical and financial ramifications of IC may help direct future quality improvement efforts.
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Affiliation(s)
| | | | - Kurt F Heiss
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Mark L Wulkan
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Mehul V Raval
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia
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145
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Richards MK, Goldin AB, Savinkina A, Doski J, Goldfarb M, Nuchtern J, Langer M, Beierle EA, Vasudevan S, Gow KW, Raval MV. The association between nephroblastoma-specific outcomes and high versus low volume treatment centers. J Pediatr Surg 2017; 52:104-108. [PMID: 27836364 DOI: 10.1016/j.jpedsurg.2016.10.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [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: 10/09/2016] [Accepted: 10/20/2016] [Indexed: 12/18/2022]
Abstract
BACKGROUND Though the volume-outcome relationship has been well-established in adults, low mortality rates and small sample sizes have precluded definitive demonstration in children. This study compares treatment-specific factors for children with nephroblastoma at high (HVC) versus low volume centers (LVC). METHODS We performed a retrospective cohort study comparing patients ≤18years with unilateral nephroblastoma treated at HVCs and LVCs using the National Cancer Data Base (1998-2012). Definitions of HVCs included performing above the median, the upper two quartiles, and the highest decile of nephroblastoma resections. Outcomes included nodal sampling, margin status, time to chemotherapy and radiation, and survival. Statistical analyses included χ2, t-tests, generalized linear, and Cox regression models (p<0.05). RESULTS Of 2911 patients from 210 centers, 1443 (49.6%) were treated at HVCs. There was no difference in frequency of preoperative biopsy or days to radiation (p>0.05). High volume centers were more likely to perform nodal sampling (RR 1.04, 95%CI 1.01-1.08) and had fewer days to chemotherapy (RR 0.80, 95%CI 0.69-0.93). Five-year survival was similar (HVC: 0.93, 95%CI 0.92-0.94; LVC: 0.93, 95%CI 0.91-0.94). CONCLUSIONS HVCs were more likely to perform nodal sampling and had fewer days to chemotherapy. There was no difference in days to radiation or survival between centers. LEVEL OF EVIDENCE Level II (retrospective prognosis study).
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Affiliation(s)
- Morgan K Richards
- University of Washington, Department of Surgery; Seattle Children's Hospital, Department of Thoracic and General Surgery.
| | - Adam B Goldin
- Seattle Children's Hospital, Department of Thoracic and General Surgery
| | | | - John Doski
- Methodist Children's Hospital of South Texas
| | | | | | | | | | | | - Kenneth W Gow
- Seattle Children's Hospital, Department of Thoracic and General Surgery
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146
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Short HL, Fevrier HB, Heiss KF, Wulkan ML, Raval MV. Association Between Operative Time and Outcomes in Children’s Surgery. J Am Coll Surg 2016. [DOI: 10.1016/j.jamcollsurg.2016.08.421] [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: 11/24/2022]
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147
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Sarda S, Short HL, Hockenberry JM, McCarthy I, Raval MV. Cross-Sectional Trends of Common Surgical Procedures at Children’s and Non-Children’s Hospitals Between 2000 and 2012. J Am Coll Surg 2016. [DOI: 10.1016/j.jamcollsurg.2016.06.221] [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: 11/17/2022]
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148
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Partain KN, Patel A, Travers C, McCracken C, Loewen J, Braithwaite K, Heiss KF, Raval MV. Secondary signs may improve the diagnostic accuracy of equivocal ultrasounds for suspected appendicitis in children. J Pediatr Surg 2016; 51:1655-60. [PMID: 27039121 PMCID: PMC5018916 DOI: 10.1016/j.jpedsurg.2016.03.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [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: 01/14/2016] [Accepted: 03/04/2016] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Ultrasound (US) is the preferred imaging modality for evaluating appendicitis. Our purpose was to determine if including secondary signs (SS) improve diagnostic accuracy in equivocal US studies. METHODS Retrospective review identified 825 children presenting with concern for appendicitis and with a right lower quadrant (RLQ) US. Regression models identified which SS were associated with appendicitis. Test characteristics were demonstrated. RESULTS 530 patients (64%) had equivocal US reports. Of 114 (22%) patients with equivocal US undergoing CT, those with SS were more likely to have appendicitis (48.6% vs 14.6%, p<0.001). Of 172 (32%) patients with equivocal US admitted for observation, those with SS were more likely to have appendicitis (61.0% vs 33.6%, p<0.001). SS associated with appendicitis included fluid collection (adjusted odds ratio (OR) 13.3, 95% confidence interval (CI) 2.1-82.8), hyperemia (OR=2.0, 95%CI 1.5-95.5), free fluid (OR=9.8, 95%CI 3.8-25.4), and appendicolith (OR=7.9, 95%CI 1.7-37.2). Wall thickness, bowel peristalsis, and echogenic fat were not associated with appendicitis. Equivocal US that included hyperemia, a fluid collection, or an appendicolith had 96% specificity and 88% accuracy. CONCLUSION Use of SS in RLQ US assists in the diagnostic accuracy of appendicitis. SS may guide clinicians and reduce unnecessary CT and admissions.
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Affiliation(s)
| | - Adarsh Patel
- Emory College, Emory University, Atlanta, GA, USA
| | - Curtis Travers
- Department of Pediatrics, Emory University School of Medicine, Children’s Healthcare of Atlanta, Atlanta, GA, USA
| | - Courtney McCracken
- Department of Pediatrics, Emory University School of Medicine, Children’s Healthcare of Atlanta, Atlanta, GA, USA
| | - Jonathan Loewen
- Division of Pediatric Radiology, Department of Radiology and Imaging Services, Emory University School of Medicine, Children’s Healthcare of Atlanta, Atlanta, GA, USA
| | - Kiery Braithwaite
- Division of Pediatric Radiology, Department of Radiology and Imaging Services, Emory University School of Medicine, Children’s Healthcare of Atlanta, Atlanta, GA, USA
| | - Kurt F. Heiss
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children’s Healthcare of Atlanta, Atlanta, GA, USA
| | - Mehul V. Raval
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children’s Healthcare of Atlanta, Atlanta, GA, USA
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Partain KN, Patel AU, Travers C, McCracken C, Loewen J, Braithwaite K, Heiss KF, Raval MV. Association of Duration of Symptoms and Secondary Signs in Ultrasound for Pediatric Appendicitis. Am Surg 2016. [DOI: 10.1177/000313481608200917] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Kristin N. Partain
- Division of Pediatric Surgery Department of Surgery Emory University School of Medicine Children's Healthcare of Atlanta Atlanta, Georgia
| | - Adarsh U. Patel
- Division of Pediatric Surgery Department of Surgery Emory University School of Medicine Children's Healthcare of Atlanta Atlanta, Georgia
| | - Curtis Travers
- Department of Pediatrics Emory University School of Medicine Children's Healthcare of Atlanta Atlanta, Georgia
| | - Courtney McCracken
- Department of Pediatrics Emory University School of Medicine Children's Healthcare of Atlanta Atlanta, Georgia
| | - Jonathan Loewen
- Division of Pediatric Radiology Department of Radiology and Imaging Services Emory University School of Medicine Children's Healthcare of Atlanta Atlanta, Georgia
| | - Kiery Braithwaite
- Division of Pediatric Radiology Department of Radiology and Imaging Services Emory University School of Medicine Children's Healthcare of Atlanta Atlanta, Georgia
| | - Kurt F. Heiss
- Division of Pediatric Surgery Department of Surgery Emory University School of Medicine Children's Healthcare of Atlanta Atlanta, Georgia
| | - Mehul V. Raval
- Division of Pediatric Surgery Department of Surgery Emory University School of Medicine Children's Healthcare of Atlanta Atlanta, Georgia
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Partain KN, Patel AU, Travers C, McCracken C, Loewen J, Braithwaite K, Heiss KF, Raval MV. Association of Duration of Symptoms and Secondary Signs in Ultrasound for Pediatric Appendicitis. Am Surg 2016; 82:e266-e268. [PMID: 27670544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Affiliation(s)
- Kristin N Partain
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
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