Outcomes and Costs of Common Surgical Procedures at Children's and Nonchildren's Hospitals

Do Unpaid Children's Hospital Account Balances Correlate with Family Income or Insurance Type?

Background

Current understanding of medical debt among various income ranges and insurance carriers is limited. We analyzed median household incomes, insurance carriers, and medical debt of plastic surgery patients at a major metropolitan children's hospital.

Methods

A retrospective chart review for zip codes, insurance carriers, and account balances was conducted for 2018-2021. All patients were seen by members of the Division of Pediatric Plastic Surgery at Ann and Robert H. Lurie Children's Hospital of Chicago. Blue Cross was reported separately among other commercial insurance carriers by the hospital's business analytics department. Median household income by zip code was obtained. IBM SPSS Statistics was used to perform chi-squared tests to study the distribution of unpaid account balances by income ranges and insurance carriers.

Results

Of the 6877 patients, 630 had unpaid account balances. Significant differences in unpaid account balances existed among twelve insurance classes (P < 0.001). There were significant differences among unpaid account balances when further examined by median household income ranges for Blue Cross (P < 0.001) and other commercial insurance carriers (P < 0.001).

Conclusions

Although patients with insurance policies requiring higher out-of-pocket costs (ie, Blue Cross and other commercial insurance carriers) are generally characterized by higher household incomes, these patients were found to have higher unpaid account balances than patients with public insurance policies. This suggests that income alone is not predictive of unpaid medical debt and provides greater appreciation of lower income families who may make a more consistent effort in repaying their medical debt.

Thyroidectomy practice in pediatric population: a national perspective

PURPOSE

To examine presentations and outcomes of pediatric patients underoing thyroidectomy.

MATERIALS AND METHODS

A retrospective cross-sectional analysis of the Nationwide Readmissions Database, 2010-2014, was performed. Study population included pediatric (<18 years) inpatients undergoing thyroidectomy.

RESULTS

A total of 361 patients were included. Mean age was 13.5 ± 0.2 years, and 79.8% were female. Thyroid diseases included: (i) 19.0% thyroid cancer, (ii) 5.4% Multiple Endocrine Neoplasia type II, (iii) 33.6% toxic nodular disease, and (iv) 42.0% non-toxic benign disease. Total thyroidectomy was performed in 67.7% of the patients, and 3.2% of the patients who had initial lobectomy were readmitted within 3 months for completion thyroidectomy. Postoperative complications were reported in 14.2% of the sample, and hypocalcemia was the most common complication (98.2%). Risk of hypocalcemia was significantly higher in patients who had thyroid cancer (risk = 20.9%, p = 0.011) or toxic thyroid diseases (risk = 19.8%, p = 0.033). Of the study population, 25.6% were managed exclusively in children's hospitals. Management in children's hospitals was not associated with improved outcomes or shorter hospital stay; however, it was associated with a significantly higher cost of health services [US $19,4575.0 ± 195.49 vs. US $13,788.00 ± 238.51, p < 0.001].

CONCLUSIONS

This study reports a national perspective on thyroidectomy in the pediatric population. Most thyroid surgeries performed in the pediatric population are performed for benign conditions. Most pediatric thyroidectomies are performed at low-volume centers. Surgeries performed in children's hospitals are significantly higher in cost without any associated improvement in outcomes or length of hospital stay.

Quality metrics for emergency abdominal surgery in children: a systematic review

BACKGROUND

There is variation in care quality and outcomes for children undergoing emergency abdominal surgery, such as appedectomy. Addressing this requires paediatric-specific quality metrics. The aim of this study was to identify perioperative structure and process measures that are associated with improved outcomes for these children.

METHODS

We performed a systematic review searching MEDLINE, Embase, CINAHL, Cochrane Library, and Google Scholar for articles published between January 1, 1980 and September 29, 2020 about the perioperative care of children undergoing emergency abdominal surgery. We also conducted secondary searching of references and citations, and we included international professional publications.

RESULTS

We identified and analysed 383 peer-reviewed articles and 18 grey literature publications. High-grade evidence pertaining to the perioperative care of this patient group is limited. Most of the evidence available relates to improving diagnostic accuracy using preoperative blood testing, imaging, and clinical decision tools. Processes associated with clinical outcomes include time lapse between time of presentation or initial assessment and surgery, and the use of particular analgesia and antibiotic protocols. Structural factors identified include hospital and surgeon caseload and the use of perioperative care pathways.

CONCLUSIONS

This review summarises the structural and process measures associated with outcome in paediatric emergency abdominal surgery. Such measures provide a means of evaluating care and identifying areas of practice that require quality improvement, especially in children with appendicitis.

CLINICAL TRIAL REGISTRATION

PROSPERO CRD42017055285.

Development of a Standardized Program for the Collaboration of Adult and Children's Surgeons

BACKGROUND

Children's hospitals within larger hospitals (CH/LH) have the specific clinical advantage of easily facilitated collaboration between adult and children's surgeons. These collaborations, which we have termed hybrid surgical offerings (HSOs) are often required for disease processes requiring interventions that fall outside the customary practice of children's surgeons. Formal models to describe or evaluate these practices are lacking.

METHODS

HSOs within a CH/LH were identified. Principles of systems-engineering were used to develop a standardized model (Children's Hybrid Enhanced Surgical Services [CHESS]) to describe and evaluate HSOs. Face validity was established via unstructured interviews of CH leaders and HSO surgeons. Areas for improved system-wide standardization and programmatic development were identified.

RESULTS

HSOs were identified in collaboration with adult bariatric, minimally invasive, advanced endoscopic, endocrine, thoracic, and orthopedic trauma surgical services. The CHESS framework encompassed: 1) quality improvement metrics, 2) credentialing and oversight, 3) transitions of care, 4) pediatric family-centered care, 5) maintenance of the cycle of expertise, 6) continuing medical education, 7) scholarship. While HSOs fulfilled the majority of aforementioned programmatic domains across all six HSO-providing services, areas for improvement included maintaining a cycle of expertise (33%), quality improvement metrics (50%), and pediatric family-centered care (66%).  Additional noted advantages included faster translation of adult innovation to pediatric care and facilitation of emergency interdisciplinary care.

CONCLUSION

Formal evaluation of HSOs is necessary to standardize and improve the quality of children's surgical care. Development of a structured framework such as CHESS addresses gaps in quality oversight and provides a basis for performance improvement, patient safety, and programmatic development.

Technology-Dependent Pediatric Inpatients at Children's Versus Nonchildren's Hospitals

BACKGROUND AND OBJECTIVE

Technology-dependent children (TDC) are admitted to both children's hospitals (CHs) and nonchildren's hospitals (NCHs), where there may be fewer pediatric-specific specialists or resources. Our objective was to compare the characteristics of TDC admitted to CHs versus NCHs.

METHODS

This was a multicenter, retrospective study using the 2012 Kids' Inpatient Database. We included patients aged 0 to 18 years with a tracheostomy, gastrostomy, and/or ventricular shunt. We excluded those who died, were transferred into or out of the hospital, had a length of stay (LOS) that was an extreme outlier, or had missing data for key variables. We compared patient and hospital characteristics across CH versus NCH using χ² tests and LOS and cost using generalized linear models.

RESULTS

In the final sample of 64 521 discharges, 55% of discharges of TDC were from NCHs. A larger proportion of those from CHs had higher disease severity (55% vs 49%; P < .001) and a major surgical procedure during hospitalization (28% vs 24%; P < .001). In an adjusted generalized linear model, the mean LOS was 4 days at both hospital types, but discharge from a CH was associated with a higher adjusted mean cost ($16 754 vs $12 023; P < .001).

CONCLUSIONS

Because the majority of TDC are hospitalized at NCHs, future research on TDC should incorporate NCH settings. Further studies should investigate if some may benefit from regionalization of care or earlier transfer to a CH.

Use of Spinal Anesthesia in Pediatric Laparoscopic Appendectomies: Case Series

BACKGROUND

Owing to the widespread use of general anesthesia, administration of spinal anesthesia in pediatric patients is not widely practiced. Yet there is ample positive evidence demonstrating its safety, effectiveness, and success.

OBJECTIVE

The objective of this study is to compare postoperative patient comfort, length of hospital stay, and cost-effectiveness of pediatric laparoscopic appendectomies performed under spinal and general anesthesia with the usual standard-of-care procedures employed in the hospital.

METHODS

This is a case series of 77 consecutive pediatric laparoscopic appendectomies (involving 5-8-year-old children) that took place in a hospital in Chittagong, Bangladesh, in 2019. A total of 40 patients underwent spinal anesthesia and 37 patients underwent general anesthesia. Variables such as surgery and operation theater times, pain score, incidence of postsurgery vomiting, analgesic usage, discharge times, and hospital costs were recorded. Statistical analysis was used to analyze the data as a function of anesthesia type.

RESULTS

The probability of vomiting when using spinal compared to general anesthesia was lower within the first 5 hours (P<.001) and 6 hours (P=.008) postoperation. A significant difference (P<.001) was observed between the total costs of the two procedures, with spinal anesthesia being less expensive. Patients were more likely to be discharged the same day of the procedure when spinal anesthesia was used (P=.008).

CONCLUSIONS

Spinal anesthesia has many advantages compared to general anesthesia for pediatric laparoscopic appendectomies. Patient comfort is improved due to a significant decrease in vomiting. This allows for more rapid hospital discharges and substantial cost savings, without compromising the outcome of the procedure.

Improving the diagnostic accuracy of appendicitis using a multidisciplinary pathway

BACKGROUND/PURPOSE

Improvement opportunities exist in the accuracy and timeliness of the diagnosis of childhood appendicitis. The purpose of our study was to conduct a post-implementation audit of a diagnostic pathway for children with suspected appendicitis presenting to our pediatric emergency department.

METHODS

We adopted a diagnostic pathway that utilized a validated risk of appendicitis stratification tool (Alvarado Score) with protocolized use of abdominal ultrasound for moderate risk patients. We conducted a 10% convenience sample audit of pathway patients treated over the subsequent 18-month period. Outcome measures included false negative and positive rates, sensitivity, specificity, and overall pathway accuracy.

RESULTS

One hundred thirty-four pathway patients, of which 22 (16.4%) had appendicitis confirmed pathologically, were evaluated. The risk group distribution of patients was: low risk (29%), moderate risk (60%), and high risk (11%). The negative appendectomy rate was 4.4% (reduced from 14% pre-pathway), and the false negative (missed appendicitis) rate was 3.0%. No patients received CT scans. Pathway sensitivity was 81.8%% (95% CI 59.7% to 94.8%), specificity-92.9%% (95% CI 86.4%-96.9%), and overall accuracy-91.0% (95% CI 84.9%-95.3%).

CONCLUSION

Implementation of a diagnostic pathway achieved a high level of accuracy and reduced our institutional negative appendectomy rate by 67%. The audit identified additional pathway improvement opportunities.

LEVELS OF EVIDENCE

Level IV.