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Ellul S, Shoukry M. The impact of unplanned 30-day readmission as a quality indicator in pediatric surgery. Front Surg 2023; 10:1199659. [PMID: 37325416 PMCID: PMC10264661 DOI: 10.3389/fsurg.2023.1199659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 05/16/2023] [Indexed: 06/17/2023] Open
Abstract
Introduction Hospital readmission is one of the indicators used to assess quality of service provided in healthcare. Based on accumulated knowledge, risk management teams assess data related to readmissions to find curative solutions for underlying factors. The current article's aim is investigating readmission routes within the workplace in paediatric surgery service during the first 30 days post discharge from Mater Dei Hospital (MDH). Materials and method A retrospective study of children's hospital readmissions between October 2017 and November 2019 was performed, strictly before COVID-19 pandemic. Demographics and clinical records including age, gender, pre-existing comorbidities, diagnosis during primary admission and readmission, procedure carried out, ASA grade, length of stay, and outcomes were collected. All children re-admitted under a single paediatric surgical department within 30 days from initial admission to tertiary referral hospital were included. Patients undergoing emergency visitation without subsequent admissions were excluded. Readmissions were classified into cohorts: elective and emergency, depending on the nature of primary admission. Contributing factors and outcomes were compared. Results 935 surgical admissions (221 elective and 714 emergencies) were registered at MDH over the given period, with an average hospital stay of 3.62 days. Total readmission rate was 1.7% (n = 16). 25% (n = 4) of readmissions were post elective, 75% (n = 12) post emergency admission, with an average stay of 4.37 days and no mortalities. 43.7% (n = 7) were re-admissions post-surgical intervention. Further surgical interventions were necessary in 25% (n = 4) of readmitted patients, the remainder (n = 12) treated conservatively. Conclusion Published reports concerning paediatric surgical readmission rates are limited, challenging healthcare systems. Most readmissions area voidable; therefore, healthcare workers must provide adequate strategies tailored to their resources, efficient multidisciplinary approaches with improved communication to decrease morbidity and prevent readmissions.
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Affiliation(s)
- Sarah Ellul
- Division of Paediatric Surgery, Department of Surgery, Mater Dei Hospital, Swatar, Malta
| | - Mohamed Shoukry
- Division of Paediatric surgery, Consultant Paediatric and Neonatal Surgeon, Department of Surgery, Mater Dei Hospital, Swatar, Malta
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Jukić M, Antišić J, Pogorelić Z. Incidence and causes of 30-day readmission rate from discharge as an indicator of quality care in pediatric surgery. Acta Chir Belg 2023; 123:26-30. [PMID: 33960261 DOI: 10.1080/00015458.2021.1927657] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
AIM Evaluation and comparison 30-day readmission rate (ReAd) from discharge within three year period and to note could it be a quality-of-care indicator in pediatric surgery. METHODS The case records of the patients that were readmitted within 30 days of primary surgery from January 1st2017 to December 31st2019 were identified retrospectively, for each year separately. Demographic data, diagnosis and the treatment on primary admission, length of hospital stay, and diagnosis with treatment on readmission, were collected. For each year readmissions were identified and divided into two groups (emergency and elective) based on the nature of the primary surgery. Outcomes were compared between two groups. RESULTS A total of 5392 admissions were identified among three years (2017, n = 1821; 2018, n = 1806; 2019, n = 1765). There was 1014(55.6%) elective admissions in 2017, 953(52.8%) in 2018 and 950(53.8%) in 2019. The overall ReAd rate was 0.82%, 0.99% and 0.57% for years 2017, 2018 and 2019, respectively (p = 0.348). The most common cause for readmission was appendicitis related followed by surgical site infection in different subfields. The share of the number of readmissions during the three-year period is 3.2 times higher for emergency admissions than for elective admissions (p < 0.001). The majority(>75%) of all readmission in all three years occurred in children above age of eight. Male gender was significantly more frequently associated with readmission(74.4%)(p < 0.001). CONCLUSION ReAd is a reproducible and good quality-of-care indicator in pediatric surgery. An incidence of ReAd is significantly higher in emergency admissions and an appendectomy is the most common procedure associated with ReAd.
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Affiliation(s)
- Miro Jukić
- Clinic of Pediatric Surgery, University Hospital of Split, Split, Croatia
| | - Jelena Antišić
- Department of Surgery, University of Split, School of Medicine, Split, Croatia
| | - Zenon Pogorelić
- Clinic of Pediatric Surgery, University Hospital of Split, Split, Croatia.,Department of Surgery, University of Split, School of Medicine, Split, Croatia
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Kabir SMU, Bucholc M, Walker CA, Sogaolu OO, Zeeshan S, Sugrue M. Quality Outcomes in Appendicitis Care: Identifying Opportunities to Improve Care. Life (Basel) 2020; 10:life10120358. [PMID: 33352906 PMCID: PMC7767194 DOI: 10.3390/life10120358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 12/07/2020] [Accepted: 12/16/2020] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Appendicitis is one of the most common causes of acute abdominal pain requiring surgical intervention, but the variability of diagnosis and management continue to challenge the surgeons. Aim: This study assessed patients undergoing appendectomy to identify opportunities to improve diagnostic accuracy and outcomes. METHODS An ethically approved retrospective cohort study was undertaken between March 2016 and March 2017 at a single university hospital of all consecutive adult and paediatric patients undergoing appendectomy. Demographic data including age, gender, co-morbidities, presentation and triage timings along with investigation, imaging and operative data were analysed. Appendicitis was defined as acute based on histology coupled with intraoperative grading with the American Association for the Surgery of Trauma (AAST) grades. Complications using the Clavien-Dindo classification along with 30-day re-admission rates and the negative appendectomy rates (NAR) were recorded and categorised greater and less than 25%. The use of scoring systems was assessed, and retrospective scoring performed to compare the Alvarado, Adult Appendicitis Score (AAS) and the Appendicitis Inflammatory Response (AIR) score. Results: A total of 201 patients were studied, 115 male and 86 females, of which 136/201 (67.6%) were adults and 65/201 (32.3%) paediatric. Of the adult group, 83 were male and 53 were female, and of the paediatric group, 32 were male and 33 were female. Median age was 20 years (range: 5 years to 81 years) and no patient below the age of 5 years had an appendectomy during our study period. All patients were admitted via the emergency department and median time from triage to surgical review was 2 h and 38 min, (range: 10 min to 26 h and 10 min). Median time from emergency department review to surgical review, 55 min (range: 5 min to 6 h and 43 min). Median time to operating theatre was 21 h from admission (range: 45 min to 140 h and 30 min). Out of the total patients, 173 (86.1%) underwent laparoscopic approach, 28 (13.9%) had an open approach and 12 (6.9%) of the 173 were converted to open. Acute appendicitis occurred in 166/201 (82.6%). There was no significant association between grade of appendicitis and surgeons' categorical NAR rate (p = 0.07). Imaging was performed in 118/201 (58.7%); abdominal ultrasound (US) in 53 (26.4%), abdominal computed tomography (CT) in 59 (29.2%) and both US and CT in 6 (3%). The best cut-off point was 4 (sensitivity 84.3% and specificity of 65.7%) for AIR score, 9 (sensitivity of 74.7% and specificity of 68.6%) for AAS, and 7 (sensitivity of 77.7% and specificity of 71.4%) for the Alvarado score. Twenty-four (11.9%) were re-admitted, due to pain in 16 (58.3%), collections in 3 (25%), 1 (4.2%) wound abscess, 1 (4.2%) stump appendicitis, 1 (4.2%) small bowel obstruction and 1 (4.2%) fresh rectal bleeding. CT guided drainage was performed in 2 (8.3%). One patient had release of wound collection under general anaesthetic whereas another patient had laparoscopic drain placement. A laparotomy was undertaken in 3 (12.5%) patients with division of adhesions in 1, the appendicular stump removed in 1 and 1 had multiple collections drained. CONCLUSION The negative appendectomy and re-admission rates were unacceptably high and need to be reduced. Minimising surgical variance with use of scoring systems and introduction of pathways may be a strategy to reduce NAR. New systems of feedback need to be introduced to improve outcomes.
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Affiliation(s)
- Syed Mohammad Umar Kabir
- Donegal Clinical Research Academy and Department of Surgery Letterkenny University Hospital, Letterkeny, Co. F92 AE81 Donegal, Ireland; (S.M.U.K.); (O.O.S.); (S.Z.)
| | - Magda Bucholc
- Intelligent Systems Research Centre, University of Ulster, Magee Campus, Londonderry BT48 7JL, UK;
| | - Carol-Ann Walker
- EU INTERREG Emergency Surgery Outcome Advancement Project, Centre for Personalised Medicine, X728 HG Letterkenny, Ireland;
| | - Opeyemi O. Sogaolu
- Donegal Clinical Research Academy and Department of Surgery Letterkenny University Hospital, Letterkeny, Co. F92 AE81 Donegal, Ireland; (S.M.U.K.); (O.O.S.); (S.Z.)
| | - Saqib Zeeshan
- Donegal Clinical Research Academy and Department of Surgery Letterkenny University Hospital, Letterkeny, Co. F92 AE81 Donegal, Ireland; (S.M.U.K.); (O.O.S.); (S.Z.)
| | - Michael Sugrue
- Donegal Clinical Research Academy and Department of Surgery Letterkenny University Hospital, Letterkeny, Co. F92 AE81 Donegal, Ireland; (S.M.U.K.); (O.O.S.); (S.Z.)
- EU INTERREG Emergency Surgery Outcome Advancement Project, Centre for Personalised Medicine, X728 HG Letterkenny, Ireland;
- Correspondence: ; Tel.: +353-74-918-8823; Fax: +353-74-918-8816
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Vaos G, Zavras N, Dimopoulou A, Iakomidis E, Pantalos G, Passalides A. Safety assessment of open appendectomies for complicated acute appendicitis in children: a comparison of trainees and specialists. Pediatr Surg Int 2020; 36:1181-1187. [PMID: 32676829 DOI: 10.1007/s00383-020-04713-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [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: 07/06/2020] [Indexed: 11/30/2022]
Abstract
PURPOSE The aim of this study was to compare the outcome of children with complicated acute appendicitis (CAA) who underwent open appendectomy (OA) performed either by trainees under the direct supervision of an SPS, or an SPS. METHODS Two hundred thirty eight patients with CAA were reviewed operated on either by a junior trainee (JT) or a senior trainee (ST) under the direct supervision of an SPS or by an SPS. The outcome measures were the overall rate of complications, operative time (OT), length of hospital stay (LHS) and 30-day readmission rate. RESULTS No statistical differences were observed between the three groups regarding the overall complication rates and 30-day readmission rate. Although, no statistical differences were observed in the mean OT between the three groups, the mean OT for perforated appendicitis (PA) performed by JTs was significantly longer than when performed by SPSs (p 0.012). Furthermore, there was a statistically significant difference between JTs and SPSs in terms of LHS for patients with PA (p 0.028). CONCLUSION This study suggests that no statistical differences were observed between the supervised trainees and SPSs regarding the overall complication rate and 30-readmission rate when they performed OA for GA or PA except of a longer OT and LHS for PA performed by JTs.
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Affiliation(s)
- George Vaos
- Department of Pediatric Surgery, "ATTIKON" University General Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.
| | - Nick Zavras
- Department of Pediatric Surgery, "ATTIKON" University General Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Anastasia Dimopoulou
- Department of Pediatric Surgery, "ATTIKON" University General Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Emmanouil Iakomidis
- Department of Pediatric Surgery, "ATTIKON" University General Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - George Pantalos
- Second Department of Pediatric Surgery, P & A Kyriakou Children's Hospital, Thivon & Levadias Str, 11527, Athens, Greece
| | - Alexander Passalides
- Second Department of Pediatric Surgery, P & A Kyriakou Children's Hospital, Thivon & Levadias Str, 11527, Athens, Greece
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Cameron DB, Serres SK, Glass CC, Milliren CE, Graham DA, Anandalwar S, Thangarajah H, Goldin AB, Hall M, Rangel SJ. Leveraging the Incidence, Burden, and Fiscal Implications of Unplanned Hospital Revisits for the Prioritization of Prevention Efforts in Pediatric Surgery. Ann Surg 2020; 271:191-9. [PMID: 29927779 DOI: 10.1097/SLA.0000000000002885] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To characterize procedure-level burden of revisit-associated resource utilization in pediatric surgery with the goal of establishing a prioritization framework for prevention efforts. SUMMARY OF BACKGROUND DATA Unplanned hospital revisits are costly to the health care system and associated with lost productivity on behalf of patients and their families. Limited objective data exist to guide the prioritization of prevention efforts within pediatric surgery. METHODS Using the Pediatric Health Information System (PHIS) database, 30-day unplanned revisits for the 30 most commonly performed pediatric surgical procedures were reviewed from 47 children's hospitals between January 1, 2012 and March 31, 2015. The relative contribution of each procedure to the cumulative burden of revisit-associated length of stay and cost from all procedures was calculated as an estimate of public health relevance if prevention efforts were successfully applied (higher relative contribution = greater potential public health relevance). RESULTS 159,675 index encounters were analyzed with an aggregate 30-day revisit rate of 10.8%. Four procedures contributed more than half of the revisit-associated length of stay burden from all procedures, with the highest relative contributions attributable to complicated appendicitis (18.4%), gastrostomy (13.4%), uncomplicated appendicitis (13.0%), and fundoplication (9.4%). Four procedures contributed more than half of the revisit-associated cost burden from all procedures, with the highest relative contributions attributable to complicated appendicitis (18.8%), gastrostomy (14.6%), fundoplication (10.4%), and uncomplicated appendicitis (10.2%). CONCLUSIONS AND RELEVANCE A small number of procedures account for a disproportionate burden of revisit-associated resource utilization in pediatric surgery. Gastrostomy, fundoplication, and appendectomy should be considered high-priority targets for prevention efforts within pediatric surgery.
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Sinha CK, Rye E, Sunderland R, Rex D, Nicholls E, Okoye B. The need for Paediatric Emergency Laparotomy Audit (PELA) in the UK. Ann R Coll Surg Engl 2020; 102:209-213. [PMID: 31660765 PMCID: PMC7027412 DOI: 10.1308/rcsann.2019.0141] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/07/2019] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION The National Emergency Laparotomy Audit (NELA) has raised serious concerns about the processes of care and outcomes in adult emergency laparotomies in the UK. To date, no comparable data have been published for children. The aim of this study was to investigate the need for a similar audit in children. METHODS Data were collected retrospectively following NELA guidelines. Results were analysed using QuickCalcs (GraphPad Software, La Jolla, CA, US). RESULTS The study period spanned 7.5 years. A total of 161 patients were identified for inclusion in the audit. The median patient age was 2.8 years. Half (49%) of the cohort were deemed ASA (American Society of Anesthesiologists) grade ≥2. A history of previous abdominal surgery was noted in 37% of the patients. The median time from admission to operation was 15 hours. Over a third (39%) of the operations were performed out of hours. The most common indications for surgery comprised adhesive bowel obstruction (37%), intussusception (27%) and volvulus (9%).The median length of hospital stay was 8 days with the median postoperative stay being 6 days (NELA data 10.6 days). Half (51%) of the cases required intensive care following surgery. The 30-day mortality rate was 3.1%. The overall mortality rate was 4.3% (NELA data 16%). Patient care was led by a consultant surgeon in 100% of cases (NELA data 89%). CONCLUSIONS This is the first study in children that provides baseline data about the standards of care and outcomes from a single centre paediatric emergency laparotomy audit. A larger study using data from multiple centres would be of great benefit.
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Affiliation(s)
- CK Sinha
- St George’s University Hospitals NHS Foundation Trust, UK
| | - E Rye
- St George’s University Hospitals NHS Foundation Trust, UK
| | - R Sunderland
- St George’s University Hospitals NHS Foundation Trust, UK
| | - D Rex
- St George’s University Hospitals NHS Foundation Trust, UK
| | - E Nicholls
- St George’s University Hospitals NHS Foundation Trust, UK
| | - B Okoye
- St George’s University Hospitals NHS Foundation Trust, UK
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Zheng C, Zhou H, Zhu H, Chen B, Qiu L, Guo C. Understanding unplanned readmissions for children undergoing surgery in a single pediatric general surgical department. BMC Pediatr 2019; 19:340. [PMID: 31554504 PMCID: PMC6761708 DOI: 10.1186/s12887-019-1672-7] [Citation(s) in RCA: 3] [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] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Accepted: 08/15/2019] [Indexed: 11/10/2022] Open
Abstract
Background The aim of the current research was to investigate the unplanned readmission rates and identify the risk factors of unplanned readmissions in pediatric general surgical specialties. Methods A retrospective review of unplanned readmissions following initial surgery from July 1, 2010, to June 30, 2017, in the general surgical specialties at an academic tertiary care hospital was performed. The main outcome of interest was unplanned readmission rates, the common causes for readmission. The risk factors involved in the unplanned readmissions were further investigated using univariate and multivariate analyses. Results Of the 3263 patients who underwent surgery and discharge, 176 (9%) were unplanned readmissions. The most frequent surgical operation related to readmission was appendectomy, and the common readmission causes were associated with treatment of gastrointestinal complaints/complications. Multivariable analysis demonstrated that emergency surgery (p = 0.016, odds ratio [OR] = 2.73; 95% CI = 1.35–6.19), major complications (p = 0.042, OR = 2.43; 95% CI = 1.12–4.71) and the initial hospital length of stay (p = 0.036, OR = 3.46; 95% CI = 1.67–7.53) were independent risk factors for readmission. Conclusions This study identified potential risks for readmission, which should be targeted for interventions to improve quality and resource allocation.
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Affiliation(s)
- Chao Zheng
- Department of Pediatric General Surgery, Children's Hospital, Chongqing Medical University, Chongqing, People's Republic of China
| | - Hong Zhou
- Department of Pediatric General Surgery, Children's Hospital, Chongqing Medical University, Chongqing, People's Republic of China
| | - Hai Zhu
- Department of Pediatric General Surgery, Children's Hospital, Chongqing Medical University, Chongqing, People's Republic of China
| | - Bailin Chen
- Department of Pediatric General Surgery, Children's Hospital, Chongqing Medical University, Chongqing, People's Republic of China.,Ministry of Education Key Laboratory of Child Development and Disorders, Children's Hospital, Chongqing Medical University, 136, 2nd Rd. Chongqing, Zhongshan, 400014, People's Republic of China
| | - Lin Qiu
- Department of Pediatric General Surgery, Children's Hospital, Chongqing Medical University, Chongqing, People's Republic of China.
| | - Chunbao Guo
- Department of Pediatric General Surgery, Children's Hospital, Chongqing Medical University, Chongqing, People's Republic of China. .,Ministry of Education Key Laboratory of Child Development and Disorders, Children's Hospital, Chongqing Medical University, 136, 2nd Rd. Chongqing, Zhongshan, 400014, People's Republic of China.
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Maltenfort MG, Chen Y, Forrest CB. Prediction of 30-day pediatric unplanned hospitalizations using the Johns Hopkins Adjusted Clinical Groups risk adjustment system. PLoS One 2019; 14:e0221233. [PMID: 31415648 PMCID: PMC6695224 DOI: 10.1371/journal.pone.0221233] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Accepted: 08/01/2019] [Indexed: 11/20/2022] Open
Abstract
Background The Johns Hopkins ACG System is widely used to predict patient healthcare service use and costs. Most applications have focused on adult populations. In this study, we evaluated the use of the ACG software to predict pediatric unplanned hospital admission in a given month, based on the past year’s clinical information captured by electronic health records (EHRs). Methods and findings EHR data from a multi-state pediatric integrated delivery system were obtained for 920,051 patients with at least one physician visit during January 2009 to December 2016. Over this interval an average of 0.36% of patients each month had an unplanned hospitalization. In a 70% training sample, we used the generalized linear mixed model (GLMM) to generate regression coefficients for demographic, clinical predictors derived from the ACG system, and prior year hospitalizations. Applying these coefficients to a 30% test sample to generate risk scores, we found that the area under the receiver operator characteristic curve (AUC) was 0.82. Omitting prior hospitalizations decreased the AUC from 0.82 to 0.80, and increased under-estimation of hospitalizations at the greater risk levels. Patients in the top 5% of risk scores accounted for 43% and the top 1% of risk scores accounted for 20% of all unplanned hospitalizations. Conclusions A predictive model based on 12-months of demographic and clinical data using the ACG system has excellent predictive performance for 30-day pediatric unplanned hospitalization. This model may be useful in population health and care management applications targeting patients likely to be hospitalized. External validation at other institutions should be done to confirm our results.
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Affiliation(s)
- Mitchell G. Maltenfort
- Applied Clinical Research Center, Roberts Center for Pediatric Research, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, United States of America
- * E-mail:
| | - Yong Chen
- Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Christopher B. Forrest
- Applied Clinical Research Center, Roberts Center for Pediatric Research, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, United States of America
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Mears AL, Bisharat M, Murphy F, Sinha CK. Readmission within 30 days of discharge (ReAd): a quality-of-care indicator in paediatric surgery. Pediatr Surg Int 2019; 35:597-602. [PMID: 30778702 DOI: 10.1007/s00383-019-04449-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [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] [Accepted: 01/30/2019] [Indexed: 10/27/2022]
Abstract
PURPOSE Following a previously published 1 year audit of readmissions, this is a reaudit of our readmission rate (ReAd) in paediatric surgery, asking: is ReAd reproducible, can it be an indicator of quality of care in paediatric surgery, and can it be improved? METHOD Prospectively collected Hospital Episode statistics were used to identify readmissions over 1 year. Patients were subdivided into emergency vs elective regarding the first admission and outcomes compared including with our previously published ReAd data. RESULTS 2616 children (67% male) were admitted during 2016: 1398 (53%) elective and 1218 (47%) emergency admissions. The overall ReAd was 0.9%, comparable to and lower than our previously published rate of 2%. The commonest cause for readmission was appendicitis-related (22%). The emergency cohort ReAd was 1.5% (18/1218) compared to 0.4% (5/1398) in the elective cohort, 4× higher (p = 0.002). In the emergency cohort, the commonest causes for readmission were abdominal pain and perforated appendicitis. 80% of elective group readmissions were related to urological procedures. More of these required surgical intervention to treat (80% vs 22%) (p = 0.03). CONCLUSION (1) ReAd is a reproducible and reducible quality-of-care indicator in paediatric surgery. (2) Emergency admission is a risk factor for readmission. (3) Appendicectomy was associated with the highest ReAd.
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Affiliation(s)
- Alice Louise Mears
- Department of Urology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - May Bisharat
- Department of Urology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Feilim Murphy
- Department of Paediatric Surgery, St George's University Hospitals NHS Foundation, Trust, London, UK
| | - Chandrasen K Sinha
- Department of Paediatric Surgery, St George's University Hospitals NHS Foundation, Trust, London, UK.
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Do‐Wyeld M, Rogerson T, Court‐Kowalski S, Cundy TP, Khurana S. Fast‐track surgery for acute appendicitis in children: a systematic review of protocol‐based care. ANZ J Surg 2019; 89:1379-1385. [PMID: 30989778 DOI: 10.1111/ans.15125] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Revised: 01/08/2019] [Accepted: 01/25/2019] [Indexed: 12/21/2022]
Affiliation(s)
- Montgommery Do‐Wyeld
- Department of Paediatric SurgeryWomen's and Children's Hospital Adelaide South Australia Australia
| | - Thomas Rogerson
- Department of Paediatric SurgeryWomen's and Children's Hospital Adelaide South Australia Australia
| | - Stefan Court‐Kowalski
- Department of Paediatric SurgeryWomen's and Children's Hospital Adelaide South Australia Australia
- Discipline of SurgeryThe University of Adelaide Adelaide South Australia Australia
| | - Thomas P. Cundy
- Department of Paediatric SurgeryWomen's and Children's Hospital Adelaide South Australia Australia
- Discipline of SurgeryThe University of Adelaide Adelaide South Australia Australia
| | - Sanjeev Khurana
- Department of Paediatric SurgeryWomen's and Children's Hospital Adelaide South Australia Australia
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Kulaylat AN, Rocourt DV, Tsai AY, Martin KL, Engbrecht BW, Santos MC, Cilley RE, Hollenbeak CS, Dillon PW. Understanding readmissions in children undergoing surgery: A pediatric NSQIP analysis. J Pediatr Surg 2018; 53:1280-1287. [PMID: 28811042 DOI: 10.1016/j.jpedsurg.2017.07.021] [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] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2017] [Revised: 07/05/2017] [Accepted: 07/24/2017] [Indexed: 10/19/2022]
Abstract
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.
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Affiliation(s)
- Afif N Kulaylat
- Division of Pediatric Surgery, Penn State Children's Hospital, Penn State Health, Hershey, PA, USA.
| | - Dorothy V Rocourt
- Division of Pediatric Surgery, Penn State Children's Hospital, Penn State Health, Hershey, PA, USA
| | - Anthony Y Tsai
- Division of Pediatric Surgery, Penn State Children's Hospital, Penn State Health, Hershey, PA, USA
| | - Kathryn L Martin
- Division of Pediatric Surgery, Penn State Children's Hospital, Penn State Health, Hershey, PA, USA
| | - Brett W Engbrecht
- Division of Pediatric Surgery, Penn State Children's Hospital, Penn State Health, Hershey, PA, USA
| | - Mary C Santos
- Division of Pediatric Surgery, Penn State Children's Hospital, Penn State Health, Hershey, PA, USA
| | - Robert E Cilley
- Division of Pediatric Surgery, Penn State Children's Hospital, Penn State Health, Hershey, PA, USA
| | - Christopher S Hollenbeak
- Division of Pediatric Surgery, Penn State Children's Hospital, Penn State Health, Hershey, PA, USA; Department of Public Health Sciences, The Pennsylvania State University, College of Medicine, Hershey, PA, USA
| | - Peter W Dillon
- Division of Pediatric Surgery, Penn State Children's Hospital, Penn State Health, Hershey, PA, USA
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Polites SF, Potter DD, Glasgow AE, Klinkner DB, Moir CR, Ishitani MB, Habermann EB. Rates and risk factors of unplanned 30-day readmission following general and thoracic pediatric surgical procedures. J Pediatr Surg 2017; 52:1239-1244. [PMID: 27956070 DOI: 10.1016/j.jpedsurg.2016.11.043] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [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: 09/14/2016] [Revised: 11/10/2016] [Accepted: 11/28/2016] [Indexed: 11/17/2022]
Abstract
BACKGROUND/PURPOSE Postoperative unplanned readmissions are costly and decrease patient satisfaction; however, little is known about this complication in pediatric surgery. The purpose of this study was to determine rates and predictors of unplanned readmission in a multi-institutional cohort of pediatric surgical patients. METHODS Unplanned 30-day readmissions following general and thoracic surgical procedures in children <18 were identified from the 2012-2014 National Surgical Quality Improvement Program- Pediatric. Time-dependent rates of readmission per 30 person-days were determined to account for varied postoperative length of stay (pLOS). Patients were randomly divided into 70% derivation and 30% validation cohorts which were used for creation and validation of a risk model for readmission. RESULTS Readmission occurred in 1948 (3.6%) of 54,870 children for a rate of 4.3% per 30 person-days. Adjusted predictors of readmission included hepatobiliary procedures, increased wound class, operative duration, complications, and pLOS. The predictive model discriminated well in the derivation and validation cohorts (AUROC 0.710 and 0.701) with good calibration between observed and expected readmission events in both cohorts (p>.05). CONCLUSIONS Unplanned readmission occurs less frequently in pediatric surgery than what is described in adults, calling into question its use as a quality indicator in this population. Factors that predict readmission including type of procedure, complications, and pLOS can be used to identify at-risk children and develop prevention strategies. LEVEL OF EVIDENCE III.
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Affiliation(s)
| | | | - Amy E Glasgow
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | | | | | | | - Elizabeth B Habermann
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
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Shepard CL, Wan J. Comparison of 30-day emergency department bouncebacks after pediatric versus adult urologic surgery. J Pediatr Urol 2017; 13:389.e1-389.e6. [PMID: 28688994 PMCID: PMC5623629 DOI: 10.1016/j.jpurol.2017.04.024] [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: 12/31/2016] [Accepted: 04/29/2017] [Indexed: 12/01/2022]
Abstract
INTRODUCTION More pediatric patients seem to present to the emergency department (ED) for non-urgent matters after urologic procedures than adult patients. Under new and expanding healthcare reform, pediatric urologists may be penalized for these visits. We compare our 30-day postoperative bounceback rates to the ED and the acuity of the concerns in these populations. MATERIALS AND METHODS All urology consults at our institution are maintained on a prospectively tracked database. We identified all patients who presented to our adult or pediatric ED between July 2013 and June 2015 within 30 days of a urologic procedure. We investigated the patient demographics including age, race, insurance, distance from the home zip code to the ED, procedures performed, chief complaint in the ED, diagnosis, and treatment required. RESULTS In our pediatric group, there were 67 visits for 56 patients (19 female, 37 male, mean age 6.8 years), which represents an overall bounceback incidence of 2.7%. Of those, 19% required admission (0.60% overall readmission rate), 10% underwent a procedure (0.32% reoperative rate, 18% required catheter manipulation/placement, 13% were given a prescription (most commonly for constipation), 6% required local wound care, and 33% were reassured only). Most pediatric patients had private insurance (62.5%) and those with private insurance or who were uninsured tended to require only reassurance compared to those with Medicare/Medicaid (p = 0.053). In the adult population, there were 369 visits in 310 patients (111 female, 199 male, mean age 55.4 years) for an incidence of 4.4%. Of those, 42% were admitted (2.2% overall readmission rate), 14% underwent a procedure (0.74% reoperative rate), 11% required catheter manipulation/placement, 14% were given medication (most commonly antibiotics and narcotics), 4% were given local wound care, and 12% were reassured. Most adult patients had Medicare/Medicaid (48.7%), but insurance type was not related to treatment required (p = 0.382). On multivariable analysis, pediatric patients, closer proximity to the hospital, and earlier postoperative day at presentation to the ED were predictive of requiring only reassurance. CONCLUSIONS Compared to adults, pediatric patients are less likely to return to the ED postoperatively (p < 0.001), but they are significantly more likely to require only reassurance (p < 0.001) while adults are significantly more likely to require hospital admission (p < 0.001). In both groups, nearly one-third of patients required only catheter care or medication. This difference could have significant implications for new healthcare policy.
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Affiliation(s)
- Courtney L Shepard
- University of Michigan Department of Urology, Division of Pediatric Urology, Ann Arbor, MI, USA.
| | - Julian Wan
- University of Michigan Department of Urology, Division of Pediatric Urology, Ann Arbor, MI, USA
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Cameron DB, Graham DA, Milliren CE, Serres S, Glass CC, Goldin AB, Rangel SJ. Do all-cause revisit rates reflect the quality of pediatric surgical care provided during index encounters? J Pediatr Surg 2017; 52:1050-1055. [PMID: 28389080 DOI: 10.1016/j.jpedsurg.2017.03.034] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [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: 02/18/2017] [Accepted: 03/09/2017] [Indexed: 11/15/2022]
Abstract
PURPOSE The purpose of this study was to compare the relatedness of revisits to the index surgical encounter across different pediatric surgical procedures and to explore whether all-cause revisit rates are an accurate surrogate measure for related revisits in this cohort of children. METHODS We reviewed all-cause revisits occurring within ninety days of the thirty most commonly performed pediatric surgical procedures at 44 children's hospitals between 1/1/2012 and 3/31/2015. For each condition, a team of four surgeons reviewed revisit diagnoses and reached consensus around relatedness to the index surgical encounter. Chi-squared tests were used to test for variation in all-cause and related revisits among procedures. Spearman's correlation coefficient was used to measure the association between rankings of procedures by their all-cause and related revisit rates. RESULTS 144,535 index encounters were analyzed with an overall revisit rate of 15.0% (21,732). Significant variation was found in both the rates of all-cause revisits among procedures (ranges: 7.6-68.4%, p<0.0001), and in the relative proportions of revisits related the index surgical encounter (range: 0% to 77%, p<0.0001). Poor correlation was found between procedure rankings based on all-cause revisit rates and revisit rates related to the index admission (r=0.33, p=0.07). CONCLUSIONS The relative proportion of revisits related to the index encounter varies significantly across pediatric surgical conditions, and poor correlation exists at the procedure-level between all-cause and related revisits rates. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Danielle B Cameron
- Department of Surgery, Boston Children's Hospital - Harvard Medical School, Boston, MA
| | - Dionne A Graham
- Center for Applied Pediatric Quality Analytics, Boston Children's Hospital, Boston, MA
| | - Carly E Milliren
- Center for Applied Pediatric Quality Analytics, Boston Children's Hospital, Boston, MA
| | - Stephanie Serres
- Department of Surgery, Boston Children's Hospital - Harvard Medical School, Boston, MA
| | - Charity C Glass
- Department of Surgery, Boston Children's Hospital - Harvard Medical School, Boston, MA
| | - Adam B Goldin
- Division of General and Thoracic Surgery, Seattle Children's Hospital - University of Washington School of Medicine, Seattle, WA
| | - Shawn J Rangel
- Department of Surgery, Boston Children's Hospital - Harvard Medical School, Boston, MA.
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