Pediatric American College of Surgeons National Surgical Quality Improvement Program: feasibility of a novel, prospective assessment of surgical outcomes

Minimally invasive repair of pectus excavatum: analyzing contemporary practice in 50 ACS NSQIP-pediatric institutions

BACKGROUND

Minimally invasive repair of pectus excavatum (MIRPE) is a well-established procedure. However, morbidity rate varies widely among institutions, and the incidence of major complications remains unknown.

STUDY DESIGN

The American College of Surgeons 2012 National Surgical Quality Improvement Program-Pediatric (NSQIP-P) participant user file was utilized to identify patients who underwent MIRPE at 50 participant institutions. Outcomes of interest were overall 30-day morbidity, hospital readmission, and reoperation.

RESULTS

Chest wall repair designated MIRPE accounted for 0.6% (n = 264) of all surgical cases included in the NSQIP-P database in 2012. The median age at surgical repair was 15.2 years. Thoracoscopy was used in 83.7% of cases. No mediastinal injuries or perioperative blood transfusions were identified. The 30-day readmission rate was 3.8%. Three patients (1.1%) required re-operation due to the following complications: superficial site infection, bar displacement and pneumothorax. The overall morbidity was 3.8% with no incidences of mortality.

CONCLUSIONS

This analysis of a large prospective multicenter dataset demonstrates that major complications following MIRPE are uncommon in contemporary practice. Wound infection is the most common complication and the main cause of hospital readmission. Targeted quality improvement initiative should be focused on perioperative strategy to further reduce wound occurrences and hospital readmission.

Safety and postoperative adverse events in pediatric otologic surgery: analysis of American College of Surgeons NSQIP-P 30-Day outcomes

OBJECTIVES

Describe safety and postoperative sequelae of pediatric otologic surgery and identify predictive factors for postoperative events.

STUDY DESIGN

Retrospective cohort study of the American College of Surgeons National Surgery Quality Improvement Program-Pediatric (NSQIP-P) database.

SETTING

Data pooled from the 2012 NSQIP-P public use file (50 institutions).

SUBJECTS AND METHODS

Current procedural terminology codes were used to identify children who underwent otologic surgery. Variables of interest included demographics and 30-day postoperative events grouped as reoperation, readmission, and complication. Event rates were determined and prevalence of events compared by procedure type and within patient subgroups according to chi-square analysis. Multivariate logistic regression evaluated predictive factors for postoperative events.

RESULTS

Of 37,319 pediatric operations, 2556 (6.8%) were otologic procedures. The most common procedure was tympanoplasty (n = 893, 34.9%), followed by myringoplasty (n = 741, 30.0%), cochlear implantation (n = 464, 18.2%), and tympanomastoidectomy (n = 458, 17.9%). There were 9 reoperations (0.4%), 32 readmissions (1.3%), and 18 complications (0.7%). Children undergoing tympanomastoidectomy or cochlear implantation were more likely to be readmitted irrespective of other factors (odds ratio = 5.5, P = .010; odds ratio = 3.5, P = .083). Children <3 years old were 4 times more likely to be readmitted than older children (odds ratio = 4.4, P < .001).

CONCLUSION

Pediatric otologic procedures are common and have low rates of global 30-day postoperative events. Tympanomastoidectomy and cochlear implantation have the highest risk of 30-day readmission. Young children (<3 years) are more likely to be readmitted following these procedures. Further optimization of the NSQIP-P to include specialty and procedure-specific variables is necessary to assess complete, actionable outcomes of pediatric otologic surgery, however the present study provides a foundation to build upon for safety and quality improvement initiatives in pediatric otology.

Pre-operative prediction of surgical morbidity in children: comparison of five statistical models

BACKGROUND

The accurate prediction of surgical risk is important to patients and physicians. Logistic regression (LR) models are typically used to estimate these risks. However, in the fields of data mining and machine-learning, many alternative classification and prediction algorithms have been developed. This study aimed to compare the performance of LR to several data mining algorithms for predicting 30-day surgical morbidity in children.

METHODS

We used the 2012 National Surgical Quality Improvement Program-Pediatric dataset to compare the performance of (1) a LR model that assumed linearity and additivity (simple LR model) (2) a LR model incorporating restricted cubic splines and interactions (flexible LR model) (3) a support vector machine, (4) a random forest and (5) boosted classification trees for predicting surgical morbidity.

RESULTS

The ensemble-based methods showed significantly higher accuracy, sensitivity, specificity, PPV, and NPV than the simple LR model. However, none of the models performed better than the flexible LR model in terms of the aforementioned measures or in model calibration or discrimination.

CONCLUSION

Support vector machines, random forests, and boosted classification trees do not show better performance than LR for predicting pediatric surgical morbidity. After further validation, the flexible LR model derived in this study could be used to assist with clinical decision-making based on patient-specific surgical risks.

Return to system within 30 days of discharge following pediatric non-shunt surgery

OBJECT

Hospital readmission after discharge is a commonly used quality measure. In a previous study, the authors had documented the rate of readmission and reoperation after pediatric CSF shunt surgery. This study documents the rate of readmission and reoperation after pediatric neurosurgical procedures excluding those related to CSF shunts.

METHODS

Between May 1, 2009, and April 30, 2013, 3098 non-shunt surgeries during 2924 index admissions were performed at a single institution. Demographic, socioeconomic, and clinical characteristics were prospectively collected in the administrative, business, and clinical databases. Clinical events within the 30 days following discharge were reviewed and analyzed. The following events of interest were analyzed for risk factor associations using multivariate logistic regression: return to the emergency department (ED), all-cause readmission, readmission to the neurosurgical service, and reoperation.

RESULTS

The number of all-cause readmissions within 30 days of discharge was 304 (10.4%, 304/2924). Admission sources consisted of the ED (n = 173), hospital transfers (n = 47), and others (n = 84). One hundred eighty of the 304 readmissions were associated with an operation, but only 153 were performed by the neurosurgical service (reoperation rate = 5.2%). These procedures included wound revisions (n = 30) and first-time shunt insertions (n = 35). The remaining 124 readmissions were nonsurgical, and only 54 were admitted to the neurosurgical service for issues related to the index non-shunt surgery. Thus, the rate of related readmission was 7.1% ([153 + 54]/2924). A longer length of stay and admission to the neonatal intensive care unit during the index admission were associated with an increased likelihood of return to the ED and readmission. Certain procedures, such as baclofen pump insertion and intracranial pressure monitor placement, were also found to be associated with adverse clinical events in the 30-day period. Lastly, patients were more likely to a undergo reoperation if the index procedure had started after 3 p.m.

CONCLUSIONS

The all-cause readmission rate within 30 days of discharge after a pediatric neurosurgical procedure was 10.4%, and the rate of related readmission was 7.1%. Whether these readmissions are preventable and to what extent they are preventable requires further study.

Pediatric hospitalist comanagement of surgical patients: structural, quality, and financial considerations

Comanagement of surgical patients is occurring more commonly among adult and pediatric patients. These systems of care can vary according to institution type, comanagement structure, and type of patient. Comanagement can impact quality, safety, and costs of care. We review these implications for pediatric surgical patients.

Is NSQIP Pediatric review representative of total institutional experience for children undergoing appendectomy?

BACKGROUND/PURPOSE

NSQIP Pediatric (NSQIP-P) is a robust quality improvement effort. A limitation of the NSQIP process lies in capturing a small proportion of the total case volume. This study examines whether appendectomies captured by NSQIP-P are concordant with all appendectomies, the most commonly captured procedure in 2011.

METHODS

We compared case mix and 30-day outcomes between children undergoing an appendectomy who were included in NSQIP (n=80) and children not captured by NSQIP (n=276) during 2011 at a tertiary referral children's hospital. A single surgical case reviewer reviewed all cases using NSQIP-P methodology.

RESULTS

NSQIP-P captured 80 of a total of 356 appendectomies (22%). The case mix was similar between NSQIP and non-NSQIP groups (e.g., 31% of each group had complicated appendicitis). Outcomes were also similar; post-operative occurrences, readmissions and return to the operation room occurred at rates of 7.5% vs. 7.6%, 5% vs. 4.7%, and 3.8% vs. 4.3% respectively.

CONCLUSION

Although NSQIP-P captured a minority of the total patient population that had an appendectomy, the case mix and outcomes were similar. Our results offer reassurance that NSQIP-P data are representative of the larger population for this procedure. Whether this concordance exists for procedures less commonly performed is unknown and a focus of ongoing work.

The use of report cards and outcome measurements to improve the safety of surgical care: the American College of Surgeons National Surgical Quality Improvement Program

Postoperative adverse events occur all too commonly and contribute greatly to our large and increasing healthcare costs. Surgeons, as well as hospitals, need to know their own outcomes in order to recognise areas that need improvement before they can work towards reducing complications. In the USA, the American College of Surgeons National Surgical Quality Improvement Project (ACS NSQIP) collects clinical data that provide benchmarks for providers and hospitals. This review summarises the history of ACS NSQIP and its components, and describes the evidence that feeding outcomes back to providers, along with real-time comparisons with other hospital rates, leads to quality improvement, better patient outcomes, cost savings and overall improved patient safety. The potential harms and limitations of the program are discussed.

The incidence and risk factors for short-term morbidity and mortality in pediatric deformity spinal surgery: an analysis of the NSQIP pediatric database

STUDY DESIGN

Retrospective review of a prospective cohort.

OBJECTIVE

To determine the incidence and risk factors for 30-day morbidity and mortality after pediatric deformity spinal surgery.

SUMMARY OF BACKGROUND DATA

Pediatric deformity spinal surgery is generally considered a safe and effective treatment option. The rising costs associated with spinal surgery and related perioperative complications have received national attention. Few studies with standardized definitions and data collection methods exist.

METHODS

A large, multicenter clinical registry specifically designed to collect pediatric surgical outcomes was queried for all patients undergoing spinal deformity surgery in 2012. Current Procedural Terminology codes were used to select patients undergoing anterior, posterior, and combined fusions. Detailed patient and case characteristics were analyzed. Thirty-day morbidity and mortality rates were calculated. Univariate and multivariate logistic regression analyses were used to identify patient characteristics, comorbidities, and operative variables predictive of complication.

RESULTS

In total, 2005 pediatric patients undergoing deformity spinal fusion were included. The rate of 30-day complications was 10.0%; with a mortality rate of 0.15% (3 patients), a morbidity rate of 8.4%, reoperation rate of 3.74%, and readmission rate of 3.94%. The morbidity rate was highest in the neuromuscular group (13.09%) and lowest in the idiopathic cohort (5.69%), P < 0.01). Compared with posterior fusions, anterior fusions and those extending to the pelvis were associated with higher complication rates (P < 0.01). Risk factors for complication included hepatobiliary disease (P = 0.03), cognitive impairment (P = 0.02), elevated American Society of Anesthesiologists class (P < 0.01), and prolonged operative time (P < 0.01).

CONCLUSION

The overall rate of 30-day morbidity after pediatric spinal deformity surgery was 10%. Multiple patient comorbidities and surgical duration and invasiveness were associated with an increased complication risk. These data may aid in the informed consent process, facilitate patient risk assessment, and allow quality comparisons between surgeons and institutions.

LEVEL OF EVIDENCE

2.

The future of quality measurement in the United States

The need to practice cost efficient medicine and provide it in the safest way possible is paving the way for quality improvement (QI) programs to take off. American College of Surgeons National Surgical QI Project and Surgical Care and Outcomes Assessment Program are some of the leading examples and have provided useful data to evaluate our systems and decrease morbidity and mortality. With proven outcomes driving morbidity and mortality rates down, we have to wonder how to refine these measures to make them more relevant to specialty surgeries such as colorectal. On the contrary, participation in programs like these has placed extended requirements on hospitals and physicians. In addition, some of the quality measures may be inaccurately identifying low and high performing hospitals and individuals because of inherent flaws in the database. This could potentially be in conflict with the mission of these programs. What will be presented are some alternatives and different directions QI is moving toward.

Return to system within 30 days of discharge following pediatric shunt surgery

OBJECT

The rate of readmission after CSF shunt surgery is significant and has caught the attention of purchasers of health care. However, a detailed description of clinical scenarios that lead to readmissions and reoperations after index shunt surgery is lacking in the medical literature.

METHODS

This study included 1755 shunt revision and insertion surgeries that were performed at a single institution between May 1, 2009, and April 30, 2013. Demographic, socioeconomic, and clinical characteristics were prospectively collected in the administrative, business, and operating room databases. Clinical events within the 30 days following discharge were reviewed and analyzed. Two events of interest, Emergency Department (ED) utilization and reoperation, were further analyzed for risk factor associations by using multivariate logistic regression.

RESULTS

There were 290 readmissions within 30 days of discharge (16.5%). Admission sources included ED (n = 216), hospital transfers (n = 23), and others. Of the 290 readmissions, 184 were associated with an operation, but only 165 of these were performed by the neurosurgical service. These included surgeries for shunt occlusion and externalization (n = 150), wound revision (n = 7), and other neurosurgical procedures that were not shunt related (n = 8). The remaining readmissions (n = 106) were not associated with an operation, and only 59 patients were admitted for issues related to the index shunt surgery. When return to the ED was the dependent variable in a multivariate regression model, patients who returned to the ED were more likely to be from the Atlanta metropolitan area and to be either uninsured or insured with public assistance. When reoperation was the dependent variable, patients whose surgery started after 3 p.m. were more likely to undergo subsequent CSF shunt revision surgery on readmission.

CONCLUSIONS

Of the readmissions within 30 days of shunt surgery, 74.5% were related to the index shunt surgery. Whether and to what extent these readmissions are preventable continues to be controversial. Further study is needed to identify modifiable risk factors that may eventually improve patient care.

ACS national surgical quality improvement program: targeting quality improvement in Canadian pediatric surgery

PURPOSE

The pediatric NSQIP program is in the early stages of facilitated surgical quality improvement for children. The objective of this study is to describe the initial experience of the first Canadian Children's Hospital participant in this program.

METHOD

Randomly sampled surgical cases from the "included" case list were abstracted into the ACS-NSQIP database. These surgical procedure-specific data incorporate patient risk factors, intraoperative details, and 30 day outcomes to generate annual reports which provide hierarchical ranking of participant hospitals according to their risk-adjusted outcomes.

RESULTS

Our first risk-adjusted report identified local improvement opportunities based on our rates of surgical site infection (SSI) and urinary tract infection (UTI). We developed and implemented an engagement strategy for our stakeholders, performed literature reviews to identify practice variation, and conducted case control studies to understand local risk factors for our SSI/UTI occurrences. We have begun quality improvement activities targeting reduction in rates of SSI and UTI with our general surgery division and ward nurses, respectively.

CONCLUSIONS

The NSQIP pediatric program provides high quality outcome data that can be used in support of quality improvement. This process requires multidisciplinary teamwork, systematic stakeholder engagement, clinical research methods and process improvement through engagement and culture change.

Surgical site infections in infants admitted to the neonatal intensive care unit

BACKGROUND

Surgical interventions are common in infants admitted to the neonatal intensive care unit (NICU). Despite our awareness of the broad impact of surgical site infection (SSI), there are little data in neonates. Our objective was to determine the rate and clinical impact of SSI in infants admitted to the NICU.

METHODS

Provincial population-based study of infants admitted to a tertiary care NICU. SSI, explicitly defined, was included if it occurred within 30 days of a skin/mucosal-breaking surgical intervention.

RESULTS

Among 724 infants who underwent 1039 surgical interventions very low birth weight (VLBW) infants were over-represented. The overall SSI rate was 4.3 per 100 interventions [CI 95% 3.2 to 5.7], up to 19 per 100 dirty interventions (wound class 4) [CI 95% 4.0 to 46]. Rates were higher in infants following gastroschisis closure (13 per 100 infants [CI 95% 5.8 to 24]), whereas they were generally low following a ligation of a ductus arteriosus. Infants with SSI required longer hospitalization after adjusting for co-morbidities (p<0.001).

CONCLUSIONS

Data from this relatively large contemporary study suggest that SSI rates in the NICU setting are more comparable to the pediatric age group. However, VLBW infants and those undergoing gastroschisis closure represent high risk groups.

Return to system within 30 days of pediatric neurosurgery

OBJECT

Quality assessment measures have not been well developed for pediatric neurosurgical patients. This report documents the authors' experience in extracting information from an administrative database to establish the rate of return to system within 30 days of pediatric neurosurgical procedures.

METHODS

Demographic, socioeconomic, and clinical characteristics were prospectively collected in administrative, business, and operating room databases. The primary end point was an unexpected return to the hospital system within 30 days from the date of a pediatric neurosurgical procedure. Statistical methods were used to identify clinical and demographic factors associated with the primary end point.

RESULTS

There were 1358 pediatric neurosurgical procedures performed in the Children's Healthcare of Atlanta operating rooms in 2012, with 37.4% of these surgeries being preceded by admissions through the emergency department. Medicare or Medicaid was the payor for 54.9% of surgeries, and 37.6% of surgeries were shunt related. There were 148 unexpected returns to the system within 30 days after surgery, and in 109 of these cases, the patient had a presenting complaint that was attributable to the index surgery (related returns). The most common complaints were headache, nausea, vomiting, or seizure after shunt revision or cranial procedures (n = 62). The next most common reason for re-presentation was for wound concerns (n = 30). Thirty-seven of the 109 related returns resulted in a reoperation. The monthly rate of related returns was 8.1% ± 2.5% over the 12-month study period. When using related returns as the dependent variable, the authors found that patients who underwent a shunt-related surgery were both more likely to unexpectedly return to the system (OR 1.86, p = 0.008) and to require surgery upon readmission (OR 3.28, p = 0.004). Because an extended hospitalization shortened the window of time for readmission after surgery, extended length of stay was protective against return to system within 30 days of surgery. Importantly, if related and unrelated returns were analyzed together as the dependent variable (n = 148), no independent clinical and demographic risk factor could be identified.

CONCLUSIONS

Quality assessment measures need to be clearly and carefully defined, as the definition itself will impact the analytical results. Clinicians must play a leading role in the development of these measures to ensure their clinical meaningfulness.

Enhancing NSQIP-Pediatric through integration with the Pediatric Health Information System

PURPOSE

We implemented and validated a linkage algorithm for cases in both the National Surgical Quality Improvement Program-Pediatric (NSQIP-Peds) and the Pediatric Health Information System (PHIS) to investigate healthcare utilization during the first post-operative year.

METHODS

NSQIP-Peds and PHIS cases from our institution who were operated on between January 2010 and September 2011 were matched on gender and dates of birth, admission, and discharge. Rates of true matches were validated using medical records. We examined rates of emergency department (ED) visits, hospital readmissions, potentially preventable readmissions (PPR), and hospital charges within one year of the NSQIP-Peds encounter.

RESULTS

Of the 2,409 NSQIP-Peds and 61,147 PHIS records, 93.6% met match criteria with 92.5% being true matches. Post-operative ED visit rates were 7.8% within 30days, 17.2% between 31-180days, and 18.1% between 181-365days. Readmission rates were 5.5% within 30days, 9.3% between 31-180days, and 8.4% between 181-365days. In patients undergoing inpatient procedures, 10.6% had readmissions within 30days, and 23.7% had readmissions within 365days that were potentially preventable.

CONCLUSIONS

Using indirect identifiers, a linked NSQIP-Peds-PHIS dataset demonstrated high rates of ED visits, readmissions, and PPR in the first post-operative year. This dataset may provide a more comprehensive way to study health care utilization and clinical outcomes.

Risk-adjusted hospital outcomes for children's surgery

BACKGROUND The American College of Surgeons National Surgical Quality Improvement Program-Pediatric was initiated in 2008 to drive quality improvement in children's surgery. Low mortality and morbidity in previous analyses limited differentiation of hospital performance.

METHODS

Participating institutions included children's units within general hospitals and free-standing children's hospitals. Cases selected by Current Procedural Terminology codes encompassed procedures within pediatric general, otolaryngologic, orthopedic, urologic, plastic, neurologic, thoracic, and gynecologic surgery. Trained personnel abstracted demographic, surgical profile, preoperative, intraoperative, and postoperative variables. Incorporating procedure-specific risk, hierarchical models for 30-day mortality and morbidities were developed with significant predictors identified by stepwise logistic regression. Reliability was estimated to assess the balance of information versus error within models.

RESULTS

In 2011, 46 281 patients from 43 hospitals were accrued; 1467 codes were aggregated into 226 groupings. Overall mortality was 0.3%, composite morbidity 5.8%, and surgical site infection (SSI) 1.8%. Hierarchical models revealed outlier hospitals with above or below expected performance for composite morbidity in the entire cohort, pediatric abdominal subgroup, and spine subgroup; SSI in the entire cohort and pediatric abdominal subgroup; and urinary tract infection in the entire cohort. Based on reliability estimates, mortality discriminates performance poorly due to very low event rate; however, reliable model construction for composite morbidity and SSI that differentiate institutions is feasible.

CONCLUSIONS

The National Surgical Quality Improvement Program-Pediatric expansion has yielded risk-adjusted models to differentiate hospital performance in composite and specific morbidities. However, mortality has low utility as a children's surgery performance indicator. Programmatic improvements have resulted in actionable data.

Beyond surgical care improvement program compliance: antibiotic prophylaxis implementation gaps

BACKGROUND

Despite increased compliance with Surgical Care Improvement Project infection measures, surgical-site infections are not decreasing. The aim of this study was to test the hypothesis that documented compliance with antibiotic prophylaxis guidelines on a pediatric surgery service does not reflect implementation fidelity or adherence to guidelines as intended.

METHODS

A 7-week observational study of elective pediatric surgical cases was conducted. Adherence was evaluated for appropriate administration, type, timing, weight-based dosing, and redosing of antibiotics.

RESULTS

Prophylactic antibiotics were administered appropriately in 141 of 143 cases (99%). Of 100 cases (70%) in which antibiotic prophylaxis was indicated, compliance was documented in 100% cases in the electronic medical record, but only 48% of cases adhered to all 5 guidelines. Lack of adherence was due primarily to dosing or timing errors.

CONCLUSIONS

Lack of implementation fidelity in antibiotic prophylaxis guidelines may partly explain the lack of expected reduction in surgical-site infections. Future studies of Surgical Care Improvement Project effectiveness should measure adherence and implementation fidelity rather than just documented compliance.

An Overview of Administrative and National Survey Databases for Use in Otolaryngology Research

An emerging focus on measurement and reporting of health care quality indicators calls for a sound evidence base that otolaryngologists can use to support clinical care decisions. In addition to traditional clinical trials, practitioners are heeding results of high-quality comparative-effectiveness and health services research analyses to better understand the complexity of disease epidemiology, care variation, health care costs, and surgical utilization for common conditions. Many national publicly available data sources exist for use in clinical research that may be of benefit for the academic and clinical otolaryngologist. The strength and value of these sources vary depending on the intended use or research question. The purpose of this commentary is to introduce and provide an overview of some major national and administrative databases, highlight potential strengths and limitations of these data, and suggest applications for use in advancing the care of our patients in otolaryngology.

American College of Surgeons National Surgical Quality Improvement Program Pediatric: a beta phase report

PURPOSE

The American College of Surgeons (ACS) National Surgical Quality Improvement Program Pediatric (NSQIP-P) expanded to beta phase testing with the enrollment of 29 institutions. Data collection and analysis were aimed at program refinement and development of risk-adjusted models for inter-institutional comparisons.

METHODS

Data from the first full year of beta-phase NSQIP-P were analyzed. Patient accrual used ACS-NSQIP methodology tailored to pediatric specialties. Preliminary risk adjusted modeling for all pediatric and neonatal operations and pediatric (excluding neonatal) abdominal operations was performed for all cause morbidity (other than death) and surgical site infections (SSI) using hierarchical logistic regression methodology and eight predictor variables. Results were expressed as odds ratios with 95% confidence intervals.

RESULTS

During calendar year 2010, 29 institutions enrolled 37,141 patients. 1644 total CPT codes were entered, of which 456 accounted for 90% of the cases. 450 codes were entered only once (1.2% of cases). For all cases, overall mortality was 0.25%, overall morbidity 7.9%, and the SSI rate 1.8%. For neonatal cases, mortality was 2.39%, morbidity 18.7%, and the SSI rate 3%. For the all operations model, risk-adjusted morbidity institutional odds ratios ranged 0.48-2.63, with 9/29 hospitals categorized as low outliers and 9/29 high outliers, while risk-adjusted SSI institutional odds ratios ranged 0.36-2.04, with 2/29 hospitals low outliers and 7/29 high outliers.

CONCLUSION

This report represents the first risk-adjusted hospital-level comparison of surgical outcomes in infants and children using NSQIP-P data. Programmatic and analytic modifications will improve the impact of this program as it moves into full implementation. These results indicate that NSQIP-P has the potential to serve as a model for determining risk-adjusted outcomes in the neonatal and pediatric population with the goal of developing quality improvement initiatives for the surgical care of children.

Variability in spinal surgery outcomes among children's hospitals in the United States

BACKGROUND

We performed a retrospective cohort study of 7637 spinal fusion surgical cases from 2004 to 2006 at 38 children's hospitals participating in the Pediatric Health Information System database to evaluate the variability of in-hospital outcomes by patient factors and between facilities in children who underwent spinal surgery.

METHODS

Outcomes were stratified by whether children did or did not have neurological impairment. Multilevel multivariate logistic regression models were used to determine patient and hospital factors associated with in-hospital infections, surgical complications, and length of stay (LOS)≥10 days.

RESULTS

Neurologically impaired (NI) children (N=2117 out of 7637) represented 28% of the cases. The interhospital interquartile range of LOS for NI children was 6 to 8 days (median 7 d) and for non-neurologically impaired (NNI) children was 5 to 6 days (median 5 d). Children with NI had roughly 6 times higher rates of in-hospital infection and 3 times higher complication rates: major interhospital variation was seen for both of these outcomes. Hospital rates of infection ranged from 0% to 27% (median 10%) for NI and from 0% to 14% (median 2%) for NNI children. Complication rates ranged from 0% to 89% (median 33%) for NI and from 3% to 68% (median 9%) for NNI children. The following factors were associated with a LOS≥10 days: in-hospital infection (P<0.0001), surgical complication (P<0.0001), and anterior/posterior versus posterior-only surgery (P<0.0001). Hospital case volume was not associated with infection, surgical complication, or LOS≥10 days.

CONCLUSIONS

Substantial variation exists in reported outcomes for children undergoing spinal surgery in children's hospitals within the United States. Further study is needed to characterize hospital-level factors related to surgical outcome to direct future quality improvement.

The Children's Health Insurance Program Reauthorization Act quality measures initiatives: moving forward to improve measurement, care, and child and adolescent outcomes

In 2009, a publicly transparent evidence-informed process responded to the requirement of the Children's Health Insurance Program Reauthorization Act (CHIPRA) legislation to identify an initial core set of recommended children's health care quality measures for voluntary use by Medicaid and the Children's Health Insurance Program, which together cover almost 40 million of America's children and adolescents. Future efforts under CHIPRA will be used to improve and strengthen the initial core set, develop new measures as needed, and post improved core measure sets annually beginning in January 2013. This supplement aims to make available useful information about issues surrounding the initial core set and key concepts for moving forward toward improvement of children's health care quality measures, children's health care quality, and children's health outcomes. The set of articles in this supplement includes a detailed description of how the identification of a balanced, grounded, and parsimonious core set of children's health care quality measures was accomplished by means of an open, public process combined with an evidence-informed evaluation methodology. Additional articles note that Medicaid and Children's Health Insurance Program (CHIP) officials put a high priority on children's health care quality and desire better measures; that publicly insured children are more likely than privately insured children to experience severe, complex chronic conditions and experience poorer quality in some respects; and that some key CHIPRA topics did not yet have valid, feasible measures (eg, availability of services, duration of enrollment and coverage, most integrated health care settings, and some aspects of family experiences of care). Key stakeholders and observers provide commentary noting the unprecedented scope and nature of the CHIPRA legislation as well as noting areas in which the nation still needs to move to improve health care quality, including its measurement. These areas include greater engagement of families and health care providers in the quality measurement and improvement enterprises, collaboration across federal agencies, more emphasis on clinical effectiveness research to enhance the validity of children's health care services and quality measures, and a need to maintain an emphasis on children as the nation expands health care coverage and attention to quality for all populations. This overview also notes areas of future priorities for measure enhancement and development, including inpatient specialty, health outcomes, and a focus on inequity. We and others contributing to this supplement consider the identification of the initial core set to be a significant initial accomplishment under CHIPRA. With sufficient attention to making the measures feasible for use across Medicaid and CHIP programs, and with technical assistance, voluntary use should be facilitated. However, the initial core set is but one step on the road toward improved quality for children. The identification of future challenges and opportunities for measure enhancement will be helpful in setting and implementing a future pediatric quality research agenda.