Measuring Surgical Site Infections in Children: Comparing Clinical, Electronic, and Administrative Data

Antibiotic Management After Neonatal Enteric Operations in US Children's Hospitals

BACKGROUND

There are few evidence-based guidelines for perioperative antibiotic management in neonates who undergo enteric operations. We sought to assess antibiotic administration practices in a large population of patients who underwent operations involving enteric anastomoses and evaluate the incidence of postoperative infection and other outcomes based on antibiotic approach.

METHODS

The Pediatric Health Information Systems database was queried for patients who underwent repair of esophageal, duodenal or jejuno-ileal atresia in 2021. The type and number of consecutive days of perioperative antibiotics was determined and ICD-10 codes corresponding to infection were noted. The incidences of post operative infections (bacterial and fungal), antibiotic-resistant infections and anti-fungal medication administration were determined.

RESULTS

516 infants were identified. A wide variety of antibiotics were administered and 39 % of patients received more than one day of treatment. There were no differences in the incidence of postoperative infection between those who received more or less than one day of perioperative antibiotics for any of the operations assessed. The incidence of bacterial infection in patients treated with cefazolin or cefoxitin monotherapy was no different than that for all other regimens. There were no significant differences in the incidence of post-operative fungal infection based on antibiotic type or duration.

CONCLUSION

There was substantial variation in the duration and type of antibiotics administered after neonatal enteric operations. We identified a low incidence of infection with only one day of perioperative antibiotics and there was no evidence that longer treatment reduced infection risk. Cefazolin monotherapy was likewise associated with a low risk for perioperative infections.

STUDY TYPE

Non-interventional observational database study.

LEVEL OF EVIDENCE: 3

Modernizing Surgical Quality: A Novel Approach to Improving Detection of Surgical Site Infections in the Veteran Population

Introduction: Surgical site infections (SSIs) are an important quality measure. Identifying SSIs often relies upon a time-intensive manual review of a sample of common surgical cases. In this study, we sought to develop a predictive model for SSI identification using antibiotic pharmacy data extracted from the electronic medical record (EMR). Methods: A retrospective analysis was performed on all surgeries at a Veteran Affair's Medical Center between January 9, 2020 and January 9, 2022. Patients receiving outpatient antibiotics within 30 days of their surgery were identified, and chart review was performed to detect instances of SSI as defined by VA Surgery Quality Improvement Program criteria. Binomial logistic regression was used to select variables to include in the model, which was trained using k-fold cross validation. Results: Of the 8,253 surgeries performed during the study period, patients in 793 (9.6%) cases were prescribed outpatient antibiotics within 30 days of their procedure; SSI was diagnosed in 128 (1.6%) patients. Logistic regression identified time from surgery to antibiotic prescription, ordering location of the prescription, length of prescription, type of antibiotic, and operating service as important variables to include in the model. On testing, the final model demonstrated good predictive value with c-statistic of 0.81 (confidence interval: 0.71-0.90). Hosmer-Lemeshow testing demonstrated good fit of the model with p value of 0.97. Conclusion: We propose a model that uses readily attainable data from the EMR to identify SSI occurrences. In conjunction with local case-by-case reporting, this tool can improve the accuracy and efficiency of SSI identification.

Does a Presurgical Antisepsis Protocol Decrease Surgical Site Infections in Young Children?

National standards for surgical site infection (SSI) prevention for children remain elusive. Our institution developed a presurgical antisepsis protocol that included the three components of chlorhexidine gluconate bathing wipes, chlorhexidine gluconate oral rinse, and povidone-iodine nasal swab. This retrospective cohort study examined data from electronic health records to compare SSI rates before and after protocol implementation. We included children aged 2 through 11 years undergoing any surgical procedure with the use of an incision in the OR (N = 1,356). We did not find any difference in the occurrence of SSI before and after the protocol was implemented. Logistic regression showed that an infection present at the time of surgery was the only significant predictor of an SSI. The implementation of a presurgical antisepsis protocol was not associated with SSI rate reduction in this pediatric cohort.

Epidemiology and outcomes of surgical site infections among pediatric liver transplant recipients

INTRODUCTION

Surgical site infections (SSI) are a significant cause of morbidity in liver transplant recipients, and the current data in the pediatric population are limited. The goal of this study was to identify the incidence, classification, risk factors, and outcomes of SSIs among children undergoing liver transplantation (LT).

METHODS

A single-center, retrospective descriptive analysis was performed of patients age ≤18 years undergoing LT between September 2007 and April 2017. SSI identified within the first 30 days were analyzed. Primary endpoints included incidence, classification, risk factors, and outcomes associated with SSIs.

RESULTS

We included 86 patients, eight patients (9.3%) developed SSIs. Among segmental grafts (SG) recipients, 7/61 (11.4%) developed SSI. Among whole grafts recipients, 1/25 (4%) developed SSI. SSIs were associated with the presence of biliary complications (35% vs. 3%, p < .01; odds ratios 24, 95% CI: 3.41-487.37, p<.01). There were no differences in long term graft or patient survival associated with SSI. Patients who developed SSI were more likely to undergo reoperation (50% vs. 16.7%, p = .045) and had an increased total number of hospital days in the first 60 days post-transplant (30.5 vs. 12.5 days, p = .001).

CONCLUSIONS

SSIs after pediatric LT was less frequent than what has been previously reported in literature. SSIs were associated with the presence of biliary complications without an increase in mortality. SG had an increased rate of biliary complications without an association to SSIs but, considering its positive impact on organ shortage barriers, should not be a deterrent to the utilization of SGs.

Issues With Big Data: Variability in Reported Demographics and Complications Associated With Posterior Spinal Fusion in Pediatric Patients

BACKGROUND

Clinical and administrative registries provide large volumes of data that can be used for clinical research. However, there are several limitations relating to the quality, consistency, and generalizability of big data. In this study, we aim to compare reported demographics and certain outcomes in patients undergoing posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS), neuromuscular scoliosis (NS), and Scheuermann kyphosis (SK) between 3 commonly utilized databases in pediatric orthopaedic research.

METHODS

We used International Classification of Diseases, Ninth Revision (ICD-9), International Classification of Diseases, 10th Revision (ICD-10), and Current Procedural Terminology (CPT) codes to identify patients in the National Surgical Quality Improvement Program (NSQIP), Healthcare Cost and Utilization Project (HCUP), and Pediatric Health Information System (PHIS) between the ages of 10 to 18 that underwent PSF for AIS, SK, and NS from 2012 to 2015. We compared various demographic factors, such as sex, race/ethnicity, age, and rates of postsurgical infection and 30-day readmissions. Data was analyzed with descriptive and univariate statistics.

RESULTS

We identified 9891 patients that underwent PSF in NSQIP, 10,771 patients in PHIS, and 4335 patients in HCUP over the study period. There were significant differences in patient demographics, readmission rates, and infection rates between all patients that underwent PSF across the databases (P<0.01), as well as specifically in patients with AIS (P<0.01). HCUP had the highest proportion of Hispanic patients that underwent PSF (13.5%), as well as patients who had AIS (13.3%) or NS (17.9%). The PHIS database had the highest proportion of patients undergoing PSF for SK. Among patients with NS, there were significant differences in race across the databases (P<0.01), but no significant differences in sex, ethnicity, or readmission (P>0.05). In addition, there were significant differences in race (P=0.04) and readmission (P=0.01) across databases for patients with SK, but no differences in sex or ethnicity (P>0.05). NSQIP reported the highest rate of 30-day readmissions for patients undergoing PSF (17.9%) compared with other databases (HCUP 4.1%, PHIS 12.1%).

CONCLUSIONS

There are significant differences in patient demographics, sample sizes, and rates of complications for pediatric patients undergoing PSF across 3 commonly utilized US administrative databases. Given the variability in reported outcomes and demographics, generalizability is difficult to extrapolate from these large data sources. In addition, certain databases should be selected to appropriately power studies focusing on particular patient populations or outcomes.

Comparative analysis of robotic-assisted versus laparoscopic cholecystectomy in pediatric patients

BACKGROUND

Despite increased utilization of robotic-assisted surgery in the pediatric population during the past decade, reports of comparative analysis between robotic surgery and laparoscopic surgery are lacking. Our aim was to evaluate outcomes between pediatric robotic-assisted cholecystectomy (RC) and laparoscopic cholecystectomy (LC).

METHODS

A single institution retrospective analysis of 299 patients undergoing either RC or LC, between January 2015 and December 2018 was performed. Demographic data as well as clinical characteristics and related outcomes were abstracted and compared using univariate analysis. Related hospital costs were estimated using a charge to cost methodology.

RESULTS

The median age of the cohort was 15.5 years (IQR 14.0-17.0); 76% females and 70% white, with 74% (n = 220) undergoing LC and 26% (n = 79) undergoing RC. The majority of RC were performed using single-site technique and RC proportion increased with time (10% in 2015 vs. 41% in 2018, p<0.001). The majority of RC were more commonly attributed to patients with nonacute indications for cholecystectomy compared to acute clinical indications (87% vs. 13%). Median operative time was 98 min vs. 79 min for RC and LC respectively (p<0.001). Median postoperative LOS was similar between groups (22 h). There were no significant differences in postoperative complication, in-hospital opioid utilization and 30-day readmissions. Average total hospital costs for RC were $15,519 compared to $11,197 for LC.

CONCLUSIONS

Pediatric robotic-assisted cholecystectomy is feasible with similar outcomes compared to laparoscopic cholecystectomy. However, it is associated with longer operative times and higher costs. The single-site RC technique may provide a potential cosmetic benefit.

Additional prophylactic antibiotics do not decrease surgical site infection rates in pediatric patients with appendicitis and cholecystitis

BACKGROUND

Administration of antibiotics within an hour of incision is a common quality metric for reduction of surgical site infections (SSI). Many pediatric patients who undergo surgery for an acute intraabdominal infection are already receiving treatment antibiotics. For these patients, we hypothesized that additional prophylactic antibiotic coverage would not decrease rates of SSI.

METHODS

Single institution retrospective review of patients <18 years old undergoing appendectomy or cholecystectomy 7/2014-7/2019. Patients were categorized based on administration of an additional prophylactic antibiotic to cover gram positive bacteria within an hour of incision. The primary outcome was SSI. Secondary outcomes were Clostridium difficile colitis, intraoperative allergic reaction and readmission within 30 days due to infection.

RESULTS

Of 363 patients, 261 received pre-operative prophylactic antibiotics and 92 received treatment antibiotics only. There was no difference in rates of organ space SSI (4.3% no prophylaxis vs 4.4% prophylaxis, p = 0.97) or superficial SSI (1.1% no prophylaxis vs. 0.7% prophylaxis, p>0.999). One patient who received prophylactic antibiotics was readmitted on post-operative day 29 with C. difficile colitis. There was no difference in rates of intraoperative allergic reaction or readmission.

CONCLUSION

In pediatric patients receiving treatment antibiotics for acute intraabdominal infection, additional prophylactic antibiotics may not reduce SSIs.

Using administrative data to determine rates of surgical site infections following spinal fusion and laminectomy procedures

OBJECTIVE

Surgical site infections (SSIs) are a serious and costly post-op complication. Generating SSI rates often requires labor-intensive methods, but increasing numbers of publications reported SSI rates using administrative data.

METHODS

Index laminectomy and spinal fusion procedures were identified using Canadian Classification of Health Interventions (CCI) procedure codes for inpatients and outpatients in the province of Alberta, Canada between 2008 and 2015. SSIs occurring in the year postsurgery were identified using the International Classification of Diseases, 10th Revision, Canada (ICD-10-CA) diagnosis and CCI procedure codes indicative of post-op infection. Rates of SSIs and case characteristics were reported.

RESULTS

Over the 8-year study period, 21,222 index spinal procedures were identified of which 12,027 (56.7%) were laminectomy procedures, with 322 SSIs identified, an SSI rate of 2.7 per 100 procedures. Of the 9,195 (43.3%) fusion procedures, 298 were identified as an SSI, an SSI rate of 3.2 per 100 procedures. This study found SSI rates increased from 2008 and 2015, and rates were the highest in the 0-18 year age group.

CONCLUSIONS

The rates reported in this study were similar to published SSI rates using traditional surveillance methods, suggesting administrative data may be a viable method for reporting SSI rates following spinal procedures. Further work is needed to validate SSIs identified using administrative data by comparing to traditional surveillance.

The Impact of Preoperative Anti-TNFα Therapy on Postoperative Outcomes Following Ileocolectomy in Crohn's Disease

BACKGROUND

Controversy remains regarding the impact of anti-TNFα agents on postoperative outcomes in Crohn's disease.

METHODS

Patients (≥ 18 years) with Crohn's disease (ICD-9, 555.0-555.2, 555.9) undergoing ileocolectomy between 2005 and 2013 were identified using the Truven MarketScan® database and stratified by receipt of anti-TNFα therapy. Multivariable logistic regression was performed to evaluate anti-TNFα use on emergency department (ED) visits, postoperative complications, and readmissions at 30 days, adjusting for potential confounders. Relationships between timing of anti-TNFα administration and outcomes were examined.

RESULTS

The sample contained 2364 patients with Crohn's disease undergoing ileocolectomy, with 28.5% (n = 674) who received biologic therapy. Median duration between anti-TNFα therapy and surgery was 33 days. Postoperative ED visits and readmission rates did not significantly differ among those receiving biologics and those that did not. Overall 30-day complication rates were higher among those receiving biologic therapy, namely related to wound and infectious complications. In multivariable analysis, anti-TNFα inhibitors were associated with increased odds of postoperative complications at 30 days (aggregate complications [OR 1.6], infectious complications [OR 1.5]). There was no significant association between timing of anti-TNFα administration and occurrence of postoperative outcomes.

CONCLUSION

Anti-TNFα therapy is independently associated with increased postoperative infectious complications following ileocolectomy in Crohn's disease. However, in patients receiving anti-TNFα therapy within 90 days of operative intervention, further delaying surgery may not attenuate risk of postoperative complications.

Electronically assisted surveillance systems of healthcare-associated infections: a systematic review

Background

Surveillance of healthcare-associated infections (HAI) is the basis of each infection control programme and, in case of acute care hospitals, should ideally include all hospital wards, medical specialties as well as all types of HAI. Traditional surveillance is labour intensive and electronically assisted surveillance systems (EASS) hold the promise to increase efficiency.

Objectives

To give insight in the performance characteristics of different approaches to EASS and the quality of the studies designed to evaluate them.

Methods

In this systematic review, online databases were searched and studies that compared an EASS with a traditional surveillance method were included. Two different indicators were extracted from each study, one regarding the quality of design (including reporting efficiency) and one based on the performance (e.g. specificity and sensitivity) of the EASS presented.

Results

A total of 78 studies were included. The majority of EASS (n = 72) consisted of an algorithm-based selection step followed by confirmatory assessment. The algorithms used different sets of variables. Only a minority (n = 7) of EASS were hospital-wide and designed to detect all types of HAI. Sensitivity of EASS was generally high (> 0.8), but specificity varied (0.37–1). Less than 20% (n = 14) of the studies presented data on the efficiency gains achieved.

Conclusions

Electronically assisted surveillance of HAI has yet to reach a mature stage and to be used routinely in healthcare settings. We recommend that future studies on the development and implementation of EASS of HAI focus on thorough validation, reproducibility, standardised datasets and detailed information on efficiency.

Infections after pediatric ambulatory surgery: Incidence and risk factors

OBJECTIVE

To describe the epidemiology of surgical site infections (SSIs) after pediatric ambulatory surgery.

DESIGN

Observational cohort study with 60 days follow-up after surgery.

SETTING

The study took place in 3 ambulatory surgical facilities (ASFs) and 1 hospital-based facility in a single pediatric healthcare network.ParticipantsChildren &lt;18 years undergoing ambulatory surgery were included in the study. Of 19,777 eligible surgical encounters, 8,502 patients were enrolled.

METHODS

Data were collected through parental interviews and from chart reviews. We assessed 2 outcomes: (1) National Healthcare Safety Network (NHSN)-defined SSI and (2) evidence of possible infection using a definition developed for this study.

RESULTS

We identified 21 NSHN SSIs for a rate of 2.5 SSIs per 1,000 surgical encounters: 2.9 per 1,000 at the hospital-based facility and 1.6 per 1,000 at the ASFs. After restricting the search to procedures completed at both facilities and adjustment for patient demographics, there was no difference in the risk of NHSN SSI between the 2 types of facilities (odds ratio, 0.7; 95% confidence interval, 0.2-2.3). Within 60 days after surgery, 404 surgical patients had some or strong evidence of possible infection obtained from parental interview and/or chart review (rate, 48 SSIs per 1,000 surgical encounters). Of 306 cases identified through parental interviews, 176 cases (57%) did not have chart documentation. In our multivariable analysis, older age and black race were associated with a reduced risk of possible infection.

CONCLUSIONS

The rate of NHSN-defined SSI after pediatric ambulatory surgery was low, although a substantial additional burden of infectious morbidity related to surgery might not have been captured by standard surveillance strategies and definitions.

Complication Rates for Pediatric Hepatectomy and Nephrectomy: A Comparison of NSQIP-P, PHIS, and KID

BACKGROUND

Three large national data sets are commonly used to assess operative outcomes in pediatric surgery; National Surgical Quality Improvement Program Pediatric (NSQIP-P), Pediatric Health Information System (PHIS), and Kids' Inpatient Data set (KID). Hepatectomy and nephrectomy are rare pediatric surgical procedures, which may benefit from large administrative data sets for the assessment of short-term complications.

MATERIALS AND METHODS

A retrospective review of NSQIP-P (2012-2015), KID (2012), and PHIS (2012-2015) was performed for hepatectomy or nephrectomy cases for children aged 0 to 18 y. Thirty-day perioperative outcomes were collected, analyzed, and compared across data sets and surgical cohorts.

RESULTS

Rates of surgical site infection, wound dehiscence, central line infection, sepsis, and venous thromboembolism were similar across NSQIP-P, PHIS, and KID in both cohorts. Rates of pneumonia and renal insufficiency were higher in PHIS and KID versus NSQIP-P in both cohorts. Blood transfusions in NSQIP-P were higher than PHIS and KID in the hepatectomy group (50.9% versus 43.0% versus 32.4%, P < 0.001), but similar across data sets in the nephrectomy cohorts (12.0% versus 14.0% versus 13.0%, P = 0.15). PHIS reported higher readmission rates than NSQIP-P for both the hepatectomy (56.5% versus 17.9%, P < 0.001) and nephrectomy (32.6% versus 7.6%,P < 0.001) cohorts. Thirty-day mortality rates were similar between NSQIP-P and PHIS, but higher in KID as compared with NSQIP-P for hepatectomy (6.4% versus 0.4%, P < 0.001) and nephrectomy (2.0% versus 0.3%, P < 0.001) cases.

CONCLUSIONS

Administrative data sets provide large sample sizes for the study of low-volume procedures in children, but there are significant variations in the reported rates of perioperative outcomes between NSQIP-P, PHIS, and KID. Therefore, surgical outcomes should be interpreted within the context of the strengths and limitations of each data set.

Risk Factors for Surgical Site Infection in Neonates: A Systematic Review of the Literature and Meta-Analysis

Purpose: Surgical site infections (SSI) contribute to postoperative morbidity and mortality in children. Our aim was to evaluate the prevalence and identify risk factors for SSI in neonates. Methods: Using a defined strategy, three investigators searched articles on neonatal SSI published since 2000. Studies on neonates and/or patients admitted to neonatal intensive care unit following cervical/thoracic/abdominal surgery were included. Risk factors were identified from comparative studies. Meta-analysis was conducted according to PRISMA guidelines using RevMan 5.3. Data are (mean ± SD) prevalence. Results: Systematic review-of 885 abstracts screened, 48 studies (27,760 neonates) were included. The incidence of SSI was 5.6% (1,564 patients). SSI was more frequent in males (61.8%), premature babies (77.4%), and following gastrointestinal surgery (95.4%). Meta-analysis-10 comparative studies (16,442 neonates; 946 SSI 5.7%) showed that predictive factors for SSI development were gestational age, birth weight, age at surgery, length of surgical procedure, number of procedure per patient, length of preoperative hospital stay, and preoperative sepsis. Conversely, preoperative antibiotic use was not significantly associated with development of SSI. Conclusions: Younger neonates and those undergoing abdominal procedures are at higher risk for SSI. Given the lack of evidence-based literature, prospective studies may help determine the risk factors for SSI in neonates.

Understanding readmissions in children undergoing surgery: A pediatric NSQIP analysis

BACKGROUND

Readmission is increasingly being utilized as an important clinical outcome and measure of hospital quality. Our aim was to delineate rates, risk factors, and reasons for unplanned readmission in pediatric surgery.

MATERIALS AND METHODS

Retrospective review of pediatric patients (n=130,274) undergoing surgery (2013-2014) at hospitals enrolled in the Pediatric National Surgical Quality Improvement Program (NSQIP-P) was performed. Logistic regression was used to model factors associated with unplanned 30-day readmission. Reasons for readmission were reviewed to determine the most common causes of readmission.

RESULTS

There were 6059 (n=4.7%) readmitted children within 30days of the index operation. Of these, 5041 (n=3.9%) were unplanned, with readmission rates ranging from 1.3% in plastic surgery to 5.2% in general pediatric surgery, and 10.8% in neurosurgery. Unplanned readmissions were associated with emergent status, comorbidities, and the occurrence of pre- or postdischarge postoperative complications. Overall, the most common causes for readmission were surgical site infections (23.9%), ileus/obstruction/gastrointestinal (16.8%), respiratory (8.6%), graft/implant/device-related (8.1%), neurologic (7.0%), or pain (5.8%). Median time from discharge to readmission was 8days (IQR: 3-14days). Reasons for readmission, time until readmission, and need for reoperative procedure (overall 28%, n=1414) varied between surgical specialties.

CONCLUSION

The reasons for readmission in children undergoing surgery are complex, varied, and influenced by patient characteristics and postoperative complications. These data inform risk-stratification for readmission in pediatric surgical populations, and help to identify potential areas for targeted interventions to improve quality. They also highlight the importance of accounting for case-mix in the interpretation of hospital readmission rates.

LEVEL OF EVIDENCE

3.

Effect of preadmission bowel preparation on outcomes of elective colorectal procedures in young children

BACKGROUND

The utility of mechanical bowel preparation (MBP) to minimize infectious complications in elective colorectal surgery is contentious. Though data is scarce in children, adult studies suggest a benefit to MBP when administered with oral antibiotics (OAB).

METHODS

After IRB approval, the Pediatric Health Information System (PHIS) was queried for young children undergoing elective colon surgery from 2011 to 2014. Patients were divided into: no bowel preparation (Group 1), MBP (Group 2), and MBP plus OAB (Group 3). Statistical significance was determined using univariate and multivariate analysis with GEE models accounting for clustering by hospital.

RESULTS

One thousand five hundred eighty-one patients met study criteria: 63.7% in Group 1, 27.1% in Group 2, and 9.2% in Group 3. Surgical complication rate was higher in Group 1 (23.3%) compared to Groups 2 and 3 (14.2% and 15.5%; P<0.001). However, median length of stay was shorter in Group 1 (4, IQR 4days) compared to Group 2 (5, IQR 3) and Group 3 (6, IQR 3) (P<0.001). 30-day readmission rates were similar. In multivariate analysis compared to patients in Group 1, the odds of surgical complications were 0.72 (95% CI 0.40-1.29, P=0.28) with MBP alone (Group 2), 1.79 (95% CI 1.28-2.52, P=0.0008) with MBP+OAB (Group 3), and 1.13 (95% CI 0.81-1.58, P=0.46) for the aggregate Group 2 plus 3.

CONCLUSION

Utilization of bowel preparation in children is variable across children's hospitals nationally, and the benefit is unclear. Given the discrepancy with adult literature, a three-armed pediatric-specific randomized controlled trial is warranted.

LEVEL OF EVIDENCE

Level III treatment study - retrospective comparative study.

Big Data and Total Hip Arthroplasty: How Do Large Databases Compare?

BACKGROUND

Use of large databases for orthopedic research has become extremely popular in recent years. Each database varies in the methods used to capture data and the population it represents. The purpose of this study was to evaluate how these databases differed in reported demographics, comorbidities, and postoperative complications for primary total hip arthroplasty (THA) patients.

METHODS

Primary THA patients were identified within National Surgical Quality Improvement Programs (NSQIP), Nationwide Inpatient Sample (NIS), Medicare Standard Analytic Files (MED), and Humana administrative claims database (HAC). NSQIP definitions for comorbidities and complications were matched to corresponding International Classification of Diseases, 9th Revision/Current Procedural Terminology codes to query the other databases. Demographics, comorbidities, and postoperative complications were compared.

RESULTS

The number of patients from each database was 22,644 in HAC, 371,715 in MED, 188,779 in NIS, and 27,818 in NSQIP. Age and gender distribution were clinically similar. Overall, there was variation in prevalence of comorbidities and rates of postoperative complications between databases. As an example, NSQIP had more than twice the obesity than NIS. HAC and MED had more than 2 times the diabetics than NSQIP. Rates of deep infection and stroke 30 days after THA had more than 2-fold difference between all databases.

CONCLUSION

Among databases commonly used in orthopedic research, there is considerable variation in complication rates following THA depending upon the database used for analysis. It is important to consider these differences when critically evaluating database research. Additionally, with the advent of bundled payments, these differences must be considered in risk adjustment models.

Analysis of Outcomes After TKA: Do All Databases Produce Similar Findings?

BACKGROUND

Use of large clinical and administrative databases for orthopaedic research has increased exponentially. Each database represents unique patient populations and varies in their methodology of data acquisition, which makes it possible that similar research questions posed to different databases might result in answers that differ in important ways.

QUESTIONS/PURPOSES

(1) What are the differences in reported demographics, comorbidities, and complications for patients undergoing primary TKA among four databases commonly used in orthopaedic research? (2) How does the difference in reported complication rates vary depending on whether only inpatient data or 30-day postoperative data are analyzed?

METHODS

Patients who underwent primary TKA during 2010 to 2012 were identified within the National Surgical Quality Improvement Programs (NSQIP), the Nationwide Inpatient Sample (NIS), the Medicare Standard Analytic Files (MED), and the Humana Administrative Claims database (HAC). NSQIP is a clinical registry that captures both inpatient and outpatient events up to 30 days after surgery using clinical reviewers and strict definitions for each variable. The other databases are administrative claims databases with their comorbidity and adverse event data defined by diagnosis and procedure codes used for reimbursement. NIS is limited to inpatient data only, whereas HAC and MED also have outpatient data. The number of patients undergoing primary TKA from each database was 48,248 in HAC, 783,546 in MED, 393,050 in NIS, and 43,220 in NSQIP. NSQIP definitions for comorbidities and surgical complications were matched to corresponding International Classification of Diseases, 9 Revision/Current Procedural Terminology codes and these coding algorithms were used to query NIS, MED, and HAC. Age, sex, comorbidities, and inpatient versus 30-day postoperative complications were compared across the four databases. Given the large sample sizes, statistical significance was often detected for small, clinically unimportant differences; thus, the focus of comparisons was whether the difference reached an absolute difference of twofold to signify an important clinical difference.

RESULTS

Although there was a higher proportion of males in NIS and NSQIP and patients in NIS were younger, the difference was slight and well below our predefined threshold for a clinically important difference. There was variation in the prevalence of comorbidities and rates of postoperative complications among databases. The prevalence of chronic obstructive pulmonary disease (COPD) and coagulopathy in HAC and MED was more than twice that in NIS and NSQIP (relative risk [RR] for COPD: MED versus NIS 3.1, MED versus NSQIP 4.5, HAC versus NIS 3.6, HAC versus NSQIP 5.3; RR for coagulopathy: MED versus NIS 3.9, MED versus NSQIP 3.1, HAC versus NIS 3.3, HAC versus NSQIP 2.7; p < 0.001 for all comparisons). NSQIP had more than twice the obesity as NIS (RR 0.35). Rates of stroke within 30 days of TKA had more than a twofold difference among all databases (p < 0.001). HAC had more than twice the rates of 30-day complications at all endpoints compared with NSQIP and more than twice the 30-day infections as MED. A comparison of inpatient and 30-day complications rates demonstrated more than twice the amount of wound infections and deep vein thromboses is captured when data are analyzed out to 30 days after TKA (p < 0.001 for all comparisons).

CONCLUSIONS

When evaluating research utilizing large databases, one must pay particular attention to the type of database used (administrative claims, clinical registry, or other kinds of databases), time period included, definitions utilized for specific variables, and the population captured to ensure it is best suited for the specific research question. Furthermore, with the advent of bundled payments, policymakers must meticulously consider the data sources used to ensure the data analytics match historical sources.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Morbidity associated with 30-day surgical site infection following nonshunt pediatric neurosurgery

OBJECTIVE Morbidity associated with surgical site infection (SSI) following nonshunt pediatric neurosurgical procedures is poorly understood. The purpose of this study was to analyze acute morbidity and mortality associated with SSI after nonshunt pediatric neurosurgery using a nationwide cohort. METHODS The authors reviewed data from the American College of Surgeons National Surgical Quality Improvement Program-Pediatric (NSQIP-P) 2012-2014 database, including all neurosurgical procedures performed on pediatric patients. Procedures were categorized by Current Procedural Terminology (CPT) codes. CSF shunts were excluded. Deep and superficial SSIs occurring within 30 days of an index procedure were identified. Deep SSIs included deep wound infections, intracranial abscesses, meningitis, osteomyelitis, and ventriculitis. The following outcomes occurring within 30 days of an index procedure were analyzed, along with postoperative time to complication development: sepsis, wound disruption, length of postoperative stay, readmission, reoperation, and death. RESULTS A total of 251 procedures associated with a 30-day SSI were identified (2.7% of 9296 procedures). Superficial SSIs were more common than deep SSIs (57.4% versus 42.6%). Deep SSIs occurred more frequently after epilepsy or intracranial tumor procedures. Superficial SSIs occurred more frequently after skin lesion, spine, Chiari decompression, craniofacial, and myelomeningocele closure procedures. The mean (± SD) postoperative length of stay for patients with any SSI was 9.6 ± 14.8 days (median 4 days). Post-SSI outcomes significantly associated with previous SSI included wound disruption (12.4%), sepsis (15.5%), readmission (36.7%), and reoperation (43.4%) (p < 0.001 for each). Post-SSI sepsis rates (6.3% vs 28.0% for superficial versus deep SSI, respectively; p < 0.001), wound disruption rates (4.9% vs 22.4%, p < 0.001), and reoperation rates (23.6% vs 70.1%, p < 0.001) were significantly greater for patients with deep SSIs. Postoperative length of stay in patients discharged before SSI development was not significantly different for deep versus superficial SSI (4.2 ± 2.7 vs 3.6 ± 2.4 days, p = 0.094). No patient with SSI died within 30 days after surgery. CONCLUSIONS Thirty-day SSI is associated with significant 30-day morbidity in pediatric patients undergoing nonshunt neurosurgery. Rates of SSI-associated complications are significantly lower in patients with superficial infection than in those with deep infection. There were no cases of SSI-related mortality within 30 days of the index procedure.

Risk factors for surgical site infection following nonshunt pediatric neurosurgery: a review of 9296 procedures from a national database and comparison with a single-center experience

OBJECTIVE Surgical site infection (SSI) following CSF shunt operations has been well studied, yet risk factors for nonshunt pediatric neurosurgery are less well understood. The purpose of this study was to determine SSI rates and risk factors following nonshunt pediatric neurosurgery using a nationwide patient cohort and an institutional data set specifically for better understanding SSI. METHODS The authors reviewed the American College of Surgeons National Surgical Quality Improvement Program-Pediatric (ACS NSQIP-P) database for the years 2012-2014, including all neurosurgical procedures performed on pediatric patients except CSF shunts and hematoma evacuations. SSI included deep (intracranial abscesses, meningitis, osteomyelitis, and ventriculitis) and superficial wound infections. The authors performed univariate analyses of SSI association with procedure, demographic, comorbidity, operative, and hospital variables, with subsequent multivariate logistic regression analysis to determine independent risk factors for SSI within 30 days of the index procedure. A similar analysis was performed using a detailed institutional infection database from Children's of Alabama (COA). RESULTS A total of 9296 nonshunt procedures were identified in NSQIP-P with an overall 30-day SSI rate of 2.7%. The 30-day SSI rate in the COA institutional database was similar (3.3% of 1103 procedures, p = 0.325). Postoperative time to SSI in NSQIP-P and COA was 14.6 ± 6.8 days and 14.8 ± 7.3 days, respectively (mean ± SD). Myelomeningocele (4.3% in NSQIP-P, 6.3% in COA), spine (3.5%, 4.9%), and epilepsy (3.4%, 3.1%) procedure categories had the highest SSI rates by procedure category in both NSQIP-P and COA. Independent SSI risk factors in NSQIP-P included postoperative pneumonia (OR 4.761, 95% CI 1.269-17.857, p = 0.021), immune disease/immunosuppressant use (OR 3.671, 95% CI 1.371-9.827, p = 0.010), cerebral palsy (OR 2.835, 95% CI 1.463-5.494, p = 0.002), emergency operation (OR 1.843, 95% CI 1.011-3.360, p = 0.046), spine procedures (OR 1.673, 95% CI 1.036-2.702, p = 0.035), acquired CNS abnormality (OR 1.620, 95% CI 1.085-2.420, p = 0.018), and female sex (OR 1.475, 95% CI 1.062-2.049, p = 0.021). The only COA factor independently associated with SSI in the COA database included clean-contaminated wound classification (OR 3.887, 95% CI 1.354-11.153, p = 0.012), with public insurance (OR 1.966, 95% CI 0.957-4.041, p = 0.066) and spine procedures (OR 1.982, 95% CI 0.955-4.114, p = 0.066) approaching significance. Both NSQIP-P and COA multivariate model C-statistics were > 0.7. CONCLUSIONS The NSQIP-P SSI rates, but not risk factors, were similar to data from a single center.