Emergency Department Utilization for Pediatric Gastrostomy Tubes Across the United States

INTRODUCTION

Emergency Department (ED) visits for gastrostomy tube complications in children represent a substantial health-care burden, and many ED visits are potentially preventable. The number and nature of ED visits to community hospitals for pediatric gastrostomy tube complications is unknown.

METHODS

Using the 2019 Nationwide Emergency Department Sample, we performed a retrospective cross-sectional analysis of pediatric patients (<18 y) with a primary diagnosis of gastrostomy tube complication. Our primary outcome was a potentially preventable ED visit, defined as an encounter that did not result in any imaging, procedures, or an inpatient admission. Univariate and multivariable logistic regression analyses were used to determine the associations between patient factors and our primary outcome.

RESULTS

We observed 32,036 ED visits at 535 hospitals and 15,165 (47.3%) were potentially preventable. The median (interquartile range) age was 2 (1, 6) years and 17,707 (55%) were male. Compared to White patients, patients with higher odds of potentially preventable visits were Black (adjusted odds ratio (aOR) [95% confidence interval {CI}]: 1.07 [1.05-1.11], P < 0.001) and Hispanic (aOR [95% CI]: 1.05 [1.02-1.08], P = 0.004). Patients with residential zip codes in the first (aOR [95% CI]: 1.08 [1.04, 1.12], P < 0.001), second (aOR [95% CI]: 1.07 [1.03, 1.11], P < 0.001), and third (aOR [95% CI]: 1.09 [1.05, 1.13], P < 0.001) median household income quartiles had higher odds of potentially preventable visits compared to the highest.

CONCLUSIONS

In a nationally representative sample of EDs, 47.3% of visits for pediatric gastrostomy tubes were potentially preventable. Efforts to improve outpatient management are warranted to reduce health-care utilization for these patients.

Disparities in Ultrasound Use for Diagnosing Pediatric Appendicitis Across United States Emergency Departments

INTRODUCTION

An ultrasound (US)-first approach for evaluating appendicitis is recommended by the American College of Radiology. We sought to assess the access to and utilization of an US-first approach for children with acute appendicitis in United States Emergency Departments.

METHODS

Utilizing the 2019 Nationwide Emergency Department Sample, we performed a retrospective cohort study of patients <18 y with a primary diagnosis of acute appendicitis based on International Classification of Disease 10th Edition Diagnosis codes. Our primary outcome was the presentation to a hospital that does not perform US for children with acute appendicitis. Our secondary outcome was the receipt of a US at US-capable hospital. We developed generalized linear models with inverse-probability weighting to determine the association between patient characteristics and outcomes.

RESULTS

Of 49,703 total children, 24,102 (48%) received a US evaluation. The odds of presenting at a hospital with no US use were significantly higher for patients aged 11-17 compared to patients <6 y (adjusted odds ratio [aOR] [95% confidence interval (CI)]: 1.59, [1.19- 2.13], P = 0.002); lowest median household income quartile compared to highest (aOR [95% CI]: 2.50, [1.52-4.10], P < 0.001); rural locations compared to metropolitan (aOR [95% CI]: 8.36 [5.54-12.6], P < 0.001), and Hispanic compared to non-Hispanic White (aOR [95% CI]: 0.63 [0.45-0.90], P = 0.01). The odds of receiving a US at US-capable hospitals were significantly lower for patients >6 y, lowest median household income quartiles, and rural locations (P < 0.05).

CONCLUSIONS

Rural, older, and poorer children are more likely to present to hospitals that do not utilize US in the diagnosis of acute appendicitis and are less likely to undergo US at US-capable hospitals.

Utility of Enteral Contrast Protocols in Pediatric Adhesive Small Bowel Obstruction: A Prospective Multicenter Observational Study

OBJECTIVE

Our objective was to determine the utility of enteral contrast-based protocols in the diagnosis and management of adhesive small bowel obstruction (ASBO) for children.

BACKGROUND

Enteral contrast-based protocols for adults with ASBO are associated with decreased need for surgery and shorter hospitalization. Pediatric-specific data are limited.

METHODS

We conducted a prospective observational study between October 2020 and December 2022 at nine children's hospitals who are members of the Western Pediatric Surgery Research Consortium. Inclusion criteria were children aged 1-20 years diagnosed with ASBO who underwent a trial of nonoperative management (NOM) at hospital admission. Comparisons were made between those children who received an enteral contrast challenge and those who did not. The primary outcome was need for surgery.

RESULTS

We enrolled 136 children (71% male; median age: 12 y); 84 (62%) received an enteral contrast challenge. There was no difference in rate of operative intervention between the no contrast (34.6%) and contrast groups (36.9%; P=0.93). Eighty-seven (64%) were successfully managed nonoperatively with no difference in median length of stay (P=0.10) or rate of unplanned readmission (P=0.14). Among the 49 children who required an operation, there was no significant difference in time from admission to surgery or rate of small bowel resection based on prior contrast administration.

CONCLUSIONS

The addition of enteral contrast-based protocols for management of pediatric ASBO does not decrease the likelihood of surgery or shorten hospitalization. Larger randomized studies may be needed to further define the role of radiologic contrast in the management of ASBO in children.

Secondary Undertriage of Pediatric Trauma Patients Across the United States Emergency Departments

INTRODUCTION

The American College of Surgeons has developed evidence-based guidelines to triage the care of severely injured children to Level 1 and 2 trauma centers. Undertriage is the treatment of patients at facilities not equipped to treat the patient's injuries appropriately. We sought to evaluate the association between patient and hospital characteristics and secondary undertriage in children after major trauma.

METHODS

We performed a retrospective cohort study using the 2019 Nationwide Emergency Department Sample. Patients aged less than 18 y were included if they presented to a Level 3 or nontrauma center (NTC) and were diagnosed with a traumatic injury with an injury severity score >15 based on International Classification of Diseases 10 codes. Our primary outcome was secondary undertriage, defined as inpatient admission to a Level 3 or NTC. We developed generalized linear models with inverse-probability survey weighting to determine the association between patient and hospital characteristics and the primary outcome.

RESULTS

Of 6572 weighted patients, 982 (15%) were undertriaged. Undertriage was significantly associated with older age (13 versus 7, P value < 0.001), metropolitan location (86% versus 68%, P < 0.001), and major abdominal injuries (19% versus 11%, P = 0.011). After multivariable adjustment, secondary undertriage was significantly associated with patients aged 6-10 y (adjusted odds ratio [aOR]: 2.47, P = 0.002) compared to patients aged 15-17 y, penetrating injury (aOR: 1.70, P = 0.011), major chest injury (aOR: 2.10, P = 0.014), and presentation at a teaching hospital (aOR: 5.66, P < 0.001).

CONCLUSIONS

After major trauma, a significant proportion of children are secondarily undertriaged at teaching NTCs. Level 1 and 2 trauma centers must partner with lower-level trauma centers to ensure children receive equitable care.

Decreased Incidence of Hirschsprung-Associated Enterocolitis During COVID-19 Across United States Children's Hospitals

BACKGROUND

The Coronavirus Disease 2019 pandemic provided a natural experiment to study the effect of social distancing on the risk of developing Hirschsprung's Associated Enterocolitis (HAEC).

METHODS

Using the Pediatric Health Information System (PHIS), a retrospective cohort study of children (<18 years) with Hirschsprung's Disease (HSCR) across 47 United States children's hospitals was performed. The primary outcome was HAEC admissions per 10,000 patient-days. The exposure (COVID-19) was defined as April 2020-December 2021. The unexposed (historical control) period was April 2018-December 2019. Secondary outcomes included sepsis, bowel perforation, intensive care unit (ICU) admission, mortality, and length of stay.

RESULTS

Overall, we included 5707 patients with HSCR during the study period. There were 984 and 834 HAEC admissions during the pre-pandemic and pandemic periods, respectively (2.6 vs. 1.9 HAEC admissions per 10,000 patient-days, incident rate ratio [95% confidence interval]: 0.74 [0.67, 0.81], p < 0.001). Compared to pre-pandemic, those with HAEC during the pandemic were younger (median [IQR]: 566 [162, 1430] days pandemic vs. 746 [259, 1609] days pre-pandemic, p < 0.001) and more likely to live in the lowest quartile of median household income zip codes (24% pandemic vs. 19% pre-pandemic, p = 0.02). There were no significant differences in rates of sepsis (6.1% pandemic vs. 6.1% pre-pandemic, p > 0.9), bowel perforation (1.3% pandemic vs. 1.2% pre-pandemic, p = 0.8), ICU admissions (9.6% pandemic vs. 12% pre-pandemic, p = 0.2), mortality (0.5% pandemic vs. 0.6% pre-pandemic, p = 0.8), or length of stay (median [interquartile range]: 4 [(Pastor et al., 2009; Gosain and Brinkman, 2015) 2,112,11 days pandemic vs. 5 [(Pastor et al., 2009; Tang et al., 2020) 2,102,10 days pre-pandemic, p = 0.4).

CONCLUSIONS

The COVID-19 pandemic was associated with significantly decreased incidence of HAEC admissions across US children's hospitals. Possible etiologies such as social distancing should be explored.

LEVEL OF EVIDENCE

II.

Pediatric cervical spine clearance: A 10-year evaluation of multidetector computed tomography at a level 1 pediatric trauma center

INTRODUCTION

Efficient and accurate evaluation of the pediatric cervical spine (c-spine) for both injury identification and posttraumatic clearance remains a challenge. We aimed to determine the sensitivity of multidetector computed tomography (MDCT) for identification of cervical spine injuries (CSIs) in pediatric blunt trauma patients.

METHODS

A retrospective cohort study was conducted at a level 1 pediatric trauma center from 2012 to 2021. All pediatric trauma patients age younger than 18 years who underwent c-spine imaging (plain radiograph, MDCT, and/or magnetic resonance imaging [MRI]) were included. All patients with abnormal MRIs but normal MDCTs were reviewed by a pediatric spine surgeon to assess specific injury characteristics.

RESULTS

A total of 4,477 patients underwent c-spine imaging, and 60 (1.3%) were diagnosed with a clinically significant CSI that required surgery or a halo. These patients were older, more likely to be intubated, have a Glasgow Coma Scale score of <14, and more likely to be transferred in from a referring hospital. One patient with a fracture on radiography and neurologic symptoms got an MRI and no MDCT before operative repair. All other patients who underwent surgery including halo placement for a clinically significant CSI had their injury diagnosed by MDCT, representing a sensitivity of 100%. There were 17 patients with abnormal MRIs and normal MDCTs; none underwent surgery or halo placement. Imaging from these patients was reviewed by a pediatric spine surgeon, and no unstable injuries were identified.

CONCLUSION

Multidetector computed tomography appears to have 100% sensitivity for detecting clinically significant CSIs in pediatric trauma patients, regardless of age or mental status. Forthcoming prospective data will be useful to confirm these results and inform recommendations for whether pediatric c-spine clearance can be safely performed based on the results of a normal MDCT alone.

LEVEL OF EVIDENCE

Diagnostic Tests or Criteria; Level IV.

Rectal Prolapse Following Repair of Anorectal Malformation: Incidence, Risk Factors, and Management

BACKGROUND

The incidence and optimal management of rectal prolapse following repair of an anorectal malformation (ARM) has not been well-defined.

METHODS

A retrospective cohort study was performed utilizing data from the Pediatric Colorectal and Pelvic Learning Consortium registry. All children with a history of ARM repair were included. Our primary outcome was rectal prolapse. Secondary outcomes included operative management of prolapse and anoplasty stricture following operative management of prolapse. Univariate analyses were performed to identify patient factors associated with our primary and secondary outcomes. A multivariable logistic regression was developed to assess the association between laparoscopic ARM repair and rectal prolapse.

RESULTS

A total of 1140 patients met inclusion criteria; 163 (14.3%) developed rectal prolapse. On univariate analysis, prolapse was significantly associated with male sex, sacral abnormalities, ARM type, ARM complexity, and laparoscopic ARM repairs (p < 0.001). ARM types with the highest rates of prolapse included rectourethral-prostatic fistula (29.2%), rectovesical/bladder neck fistula (28.8%), and cloaca (25.0%). Of those who developed prolapse, 110 (67.5%) underwent operative management. Anoplasty strictures developed in 27 (24.5%) patients after prolapse repair. After controlling for ARM type and hospital, laparoscopic ARM repair was not significantly associated with prolapse (adjusted odds ratio (95% CI): 1.50 (0.84, 2.66), p = 0.17).

CONCLUSION

Rectal prolapse develops in a significant subset of patients following ARM repair. Risk factors for prolapse include male sex, complex ARM type, and sacral abnormalities. Further research investigating the indications for operative management of prolapse and operative techniques for prolapse repair are needed to define optimal treatment.

TYPE OF STUDY

Retrospective cohort study.

LEVEL OF EVIDENCE

II.

Concurrent SARS-COV-19 and acute appendicitis: Management and outcomes across United States children's hospitals

BACKGROUND

Nonoperative management of acute appendicitis is a safe and effective alternative to appendectomy, though rates of treatment failure and disease recurrence are significant. The purpose of this study was to determine whether COVID-19-positive children with acute appendicitis were more likely to undergo nonoperative management when compared to COVID-19-negative peers and to compare clinical outcomes and healthcare use for these groups.

METHODS

A retrospective cohort study of children <18 years with acute appendicitis across 45 US Children's Hospitals during the first 12 months of the COVID-19 pandemic was performed. Operative management was defined as appendectomy or percutaneous drain placement, whereas nonoperative management was defined as admission with antibiotics alone. Multivariable hierarchical logistic regression using an exact matched cohort was used to determine the association between COVID-19 positivity and nonoperative management. The secondary outcomes included intensive care unit admission, mechanical ventilation, length of stay, nonoperative management failure rates, and hospital variation in nonoperative management.

RESULTS

Of 17,481 children in the cohort, 581 (3.3%) were positive for COVID-19. The odds of nonoperative management was significantly higher in the COVID-19-positive group (adjusted odds ratio [95% confidence interval]: 13.4 [10.7-16.8], P < .001). Patients positive for COVID-19 had increased odds of intensive care unit admission (adjusted odds ratio [95% confidence interval]: 3.78 [2.01-7.12], P < .001) and longer length of stay (median 2 days vs 1 day, P < .001). Hospital rates of nonoperative management ranged from 0% to 100% for COVID-19-positive patients and 0% to 42% for COVID-19-negative patients.

CONCLUSION

Children with concurrent acute appendicitis and COVID-19 positivity are significantly more likely to undergo nonoperative management. Both groups experience infrequent nonoperative management failure rates and rare intensive care unit admissions. Marked hospital variability in nonoperative management practices was demonstrated.

Racial and ethnic disparities in interhospital transfer for complex emergency general surgical disease across the United States

BACKGROUND

Differential access to specialty surgical care can drive health care disparities, and interhospital transfer (IHT) is one mechanism through which access barriers can be realized for vulnerable populations. The association between race/ethnicity and IHT for patients presenting with complex emergency general surgery (EGS) disease is understudied.

METHODS

Using the 2019 Nationwide Emergency Department Sample, we identified patients 18 years and older with 1 of 13 complex EGS diseases based on International Classification of Diseases, Tenth Revision , diagnosis codes. The primary outcome was IHT. A series of weighted logistic regression models was created to determine the association of race/ethnicity with the primary outcome while controlling for patient and hospital characteristics.

RESULTS

Of 387,610 weighted patient encounters from 989 hospitals, 59,395 patients (15.3%) underwent IHT. Compared with non-Hispanic White patients, rates of IHT were significantly lower for non-Hispanic Black (15% vs. 17%; unadjusted odds ratio (uOR) [95% confidence interval (CI)], 0.58 [0.49-0.68]; p < 0.001), Hispanic/Latinx (HL) (9.0% vs. 17%; uOR [95% CI], 0.48 [0.43-0.54]; p < 0.001), Asian/Pacific Islander (Asian/PI) (11% vs. 17%; uOR [95% CI], 0.84 [0.78-0.91]; p < 0.001), and other race/ethnicity (12% vs. 17%; uOR [95% CI], 0.68 [0.57-0.81]; p < 0.001) patients. In multivariable models, the adjusted odds of IHT remained significantly lower for HL (adjusted odds ratio [95% CI], 0.76 [0.72-0.83]; p < 0.001) and Asian/PI patients (adjusted odds ratio [95% CI], 0.73 [0.62-0.86]; p < 0.001) but not for non-Hispanic Black and other race/ethnicity patients ( p > 0.05).

CONCLUSION

In a nationally representative sample of emergency departments across the United States, patients of minority race/ethnicity presenting with complex EGS disease were less likely to undergo IHT when compared with non-Hispanic White patients. Disparities persisted for HL and Asian/PI patients when controlling for comorbid conditions, hospital and residential geography, neighborhood socioeconomic status, and insurance; these patients may face unique barriers in accessing surgical care.

LEVEL OF EVIDENCE

Prognostic and Epidemiologic; Level III.

Greater spatial access to care is associated with lower mortality for emergency general surgery

BACKGROUND

Emergency general surgery (EGS) diseases are time-sensitive conditions that require urgent surgical evaluation, yet the effect of geographic access to care on outcomes remains unclear. We examined the association of spatial access with outcomes for common EGS conditions.

METHODS

A retrospective analysis of twelve 2014 State Inpatient Databases, identifying adults admitted with eight EGS conditions, was performed. We assessed spatial access using the spatial access ratio (SPAR)-an advanced spatial model that accounts for travel distance, hospital capacity, and population demand, normalized against the national mean. Multivariable regression models adjusting for patient and hospital factors were used to evaluate the association between SPAR with (a) in-hospital mortality and (b) major morbidity.

RESULTS

A total of 877,928 admissions, of which 104,332 (2.4%) were in the lowest-access category (SPAR, 0) and 578,947 (66%) were in the high-access category (SPAR, ≥1), were analyzed. Low-access patients were more likely to be White, male, and treated in nonteaching hospitals. Low-access patients also had higher incidence of complex EGS disease (low access, 31% vs. high access, 12%; p < 0.001) and in-hospital mortality (4.4% vs. 2.5%, p < 0.05). When adjusted for confounding factors, including presence of advanced hospital resources, increasing spatial access was protective against in-hospital mortality (adjusted odds ratio, 0.95; 95% confidence interval, 0.94-0.97; p < 0.001). Spatial access was not significantly associated with major morbidity.

CONCLUSION

This is the first study to demonstrate that geospatial access to surgical care is associated with incidence of complex EGS disease and that increasing spatial access to care is independently associated with lower in-hospital mortality. These results support the consideration of spatial access in the development of regional health systems for EGS care.

LEVEL OF EVIDENCE

Prognostic and Epidemiologic; Level III.

Surge in Pediatric Firearm Injuries Presenting to US Children's Hospitals During the COVID-19 Pandemic

This cohort study uses administrative health data to evaluate trends in pediatric firearm injuries before and during the COVID-19 pandemic.

There is no increased risk of adjacent segment disease at the cervicothoracic junction following an anterior cervical discectomy and fusion to C7

BACKGROUND CONTEXT

Anterior cervical discectomy and fusion (ACDF) is a very common operative intervention for the treatment of cervical spine degenerative disease in those who have failed non-operative measures. However, studies examining long-term follow-up on patients who underwent ACDF reveal evidence of radiographic and clinical degenerative disc disease at the levels adjacent to the fusion construct. Consistent with other junctional regions of the spine, the cervicothoracic junction (CTJ) has significant morphologic variations. As a result, the CTJ undergoes significant static and dynamic stress. Given these findings, there has been some thought that ACDF down to C7 may experience additional risks for adjacent segment degeneration/disease (ASD) when compared with ASDFs that are cephalad to C7.

PURPOSE

The goal of this study is to evaluate the rate of radiographic and clinical ASD in patients who have undergone single- or multilevel ACDF, down to C7.

STUDY DESIGN

This is a retrospective cohort study.

PATIENT SAMPLE

The sample included consecutive patients from a single orthopedic surgeon at one quaternary referral medical center who underwent an ACDF between January 2008 and November 2014. Indications for surgery included radiculopathy, myelopathy, or myeloradiculopathy in the setting of failed conservative treatments. Patients were excluded if they had an ACDF of which the caudal level was cephalad to C7 or if they had undergone a previous cervical fusion.

OUTCOME MEASURES

Radiographic diagnosis of ASD was determined by the presence of disc space narrowing >50%, new or enlarged osteophytes, end plate sclerosis, or increased calcification of the anterior longitudinal ligament (ALL). Postoperatively, data were collected on the presence of new radicular or myelopathic symptoms indicative of pathology at C7-T1, indicating a diagnosis of clinical ASD.

METHODS

Demographic information was collected for all patients, which included age, sex, body mass index, smoking status, and Charleston Comorbidity Index (CCI). Several radiographic parameters were measured preoperatively, immediately postoperatively, and at the last follow-up: C2-C7 lordosis, sagittal vertical axis (SVA), thoracic inlet angle (TIA), and T1 slope C2-C7 lordosis were measured using the Cobb angle between the inferior end plate of C2 to the inferior end plate of C7. Radiographic and clinical factors associated with ASD were analyzed postoperatively.

RESULTS

Four patients (4.8%) presented with clinical evidence of ASD, all of whom also showed signs of radiographic ASD and improved with conservative measures. No patients underwent reoperation for ASD at the C7-T1 junction. Thirty patients (36.1%) presented radiographic evidence of ASD. These were generally older (54.4 vs. 48.4 years; p=.014). There were neither significant differences in radiographic parameters nor between single- versus multilevel ACDFs and the development of ASD.

CONCLUSIONS

The cervicothoracic junction may present with vulnerability to ASD given the junctional biomechanics. However, this study provides evidence that an ACDF with the caudal level of C7 does not incur additional risk of ASD, showing similar outcomes to ACDFs at other levels.

Variability of Reviewers' Comments in the Peer Review Process for Orthopaedic Research

STUDY DESIGN

Retrospective analysis of peer review comments.

OBJECTIVES

To assess the likelihood that comments provided by peer reviewers of one orthopaedic journal would be similar to comments of reviewers from the same journal and a second journal.

SUMMARY OF BACKGROUND DATA

The consistency of the peer review process in orthopedic research has not been objectively examined.

METHODS

Nine separate clinical papers related to spinal deformity were submitted for publication in major peer-reviewed journals and initially rejected. The exact same manuscripts were then submitted to different journals. All papers were returned with comments from two to three reviewers from each journal. Reviews were divided into distinct conceptual criticisms that were regarded as separate comments. Comments were compared between reviewers of the same journal and to comments from reviewers of the second journal.

RESULTS

When comparing comments from reviewers of the same journal, an average of 11% of comments were repeated (range 0% [0/12] to 23% [3/13]). On average, 20% of comments from the first journal were repeated by a reviewer at the second journal (range 10% [1/10] to 33% [6/18]). If a comment was made by two or more reviewers from the first journal, it had a higher likelihood (43% [6/14]) of being repeated by a reviewer from the second journal.

CONCLUSION

When an identical manuscript is submitted to a second journal after being rejected, 80% of peer review comments from the first journal are not repeated by reviewers from the second journal. One may question if addressing every peer review comment in a rejected manuscript prior to resubmission is an efficient use of resources. Comments that appear twice or more in the first journal review are more likely to reappear and may warrant special attention from the researcher.

LEVEL OF EVIDENCE

Level IV.