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Background: Appendicitis is one of the most common pediatric surgical procedures in the United States. However, wide variation remains in antibiotic prescribing and pain management across and within institutions. We aimed to minimize variation in antibiotic usage and decrease opioid prescribing at discharge for children with complicated appendicitis by implementation of a quality improvement (QI) initiative., Methods: On December 1st, 2021, a QI initiative standardizing postoperative care for complicated appendicitis was implemented across a tertiary pediatric healthcare system with two main surgical centers. QI initiative focused on antibiotic and pain management. An extensive literature search was performed and a total of 20 articles matching our patient population were critically appraised to determine the best evidence-based interventions to implement. Antibiotic regimen included: IV or PO ceftriaxone/metronidazole immediately post-operatively and transition to PO amoxicillin-clavulanic acid for completion of 7-day total course at discharge. Discharge pain control regimen included acetaminophen, ibuprofen, as needed gabapentin, and no opioid prescription. Guideline compliance were closely monitored for the first six months following implementation., Results: In the first 6-months post-implementation, compliance with use of ceftriaxone/metronidazole as initial post-operative antibiotics was 75.6 %. Transition to PO amoxicillin-clavulanic acid prior to discharge increased from 13.7 % pre-implementation to 73.7 % 6-months post-implementation (p < 0.001). Compliance with a 7-day course of antibiotics within the first 6-months post-implementation was 60 % across both sites. After QI intervention, overall opioid prescribing remained at 0 % at one surgical site and decreased from 17.6 % to 0 % at the second surgical site over the study timeframe (p < 0.001)., Conclusion: Antibiotic use can be standardized and opioid prescribing minimized in children with complicated appendicitis using QI principles. Continued monitoring of the complicated appendicitis guideline is needed to assess for further progress in the standardization of post-operative care., Study Type: Quality improvement., Level of Evidence: Level III., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Pueblo Bonito is the iconic pre- Columbian structure in Chaco Culture National Historical Park, a World Heritage Site in northwestern New Mexico, USA. The structure, dating to about 850-1150 Current Era, and built of quarried sandstones, wooden timbers and a mud mortar, has been the subject of archaeological investigations for over a century. The present study is based on the examination of historical photographs of Pueblo Bonito dating from 1887 to the 1920s. It is a retrospective assessment to determine if structural damages, depicted on the photographs, could be attributed to identifiable agents that might have been present at the time of Pueblo Bonito occupancy. A likely causal agent of deterioration at Pueblo Bonito was the inability of Ancestral Puebloan engineers to manage the impacts from the annual precipitation, presently measured at about 220 mm. A resulting time-dependent event was rot to wetted roof and ceiling timbers, lintels, and wall support beams which required decades of incubation by wood decay fungi to reduce wood tensile strength to levels leading to roof and wall collapse. Important time- independent events that could occur any time after construction include water action on the mud mortar which resulted in unstable gravity load paths in stone walls, ponding of water in walls which when frozen would lead to the blowout of wall segments, and the occasional flood that disrupted foundations. Pueblo Bonito may have been an occupation site for centuries but the lifetime of individually constructed rooms may have only been decades, resulting in several build- repair- or abandon cycles being part of the history of that Great House., Competing Interests: The authors have declared that no competing interests exist.

A thousand years ago, a population of Ancestral Puebloans occupied a high desert canyon in northwestern New Mexico, USA, where precipitation was limited and surface water scarce. Geological conditions, however, seem favorable for the production of a large Hypocrene springs system near the south canyon walls sufficient to have produced a groundwater ecosystem favorable for agriculture, tree growth, and human occupancy. A human-induced ecological impact is suggested as contributing to the dewatering of the springs, eventually reducing local agricultural production and, presumably, the suitability of Chaco Canyon for human occupancy., (© 2021 National Ground Water Association.)

Purpose: Our purpose was to examine patient- and hospital-level factors associated with nonoperative management in common pediatric surgical diagnoses., Methods: Using the 2012 Kid's Inpatient Database (KID), we identified patients <20 years old diagnosed with cholecystitis (CHOL), bowel obstruction (BO), perforated appendicitis (PA), or spontaneous pneumothorax (SPTX). Logistic regression models were used to identify factors associated with nonoperative management., Results: Of 36,026 admissions for the diagnoses of interest, 7472 (20.7%) were managed nonoperatively. SPTX had the highest incidence of NONOP (55.9%; n = 394), while PA had the lowest incidence (9.2%; n = 1641). Utilization of operative management varied significantly between hospitals. Patients diagnosed with BO (OR 0.41; 95% CI 0.30-0.56) and SPTX (OR 0.28; 95% CI 0.14-0.56) had decreased odds of operative management when treated at an urban, teaching hospital compared to a rural hospital. Patients with PA had increased odds of operative management when treated at an urban, teaching hospital (OR 2.42; 95% CI 1.78-3.30). Hospital-level factors associated with decreased odds of nonoperative management included urban, nonteaching status (OR 0.54; 95% CI 0.31-0.91) and location in the South (OR 0.53; 95% CI 0.34-83) and West (OR 0.47; 95% CI 0.30-0.74)., Conclusions: Despite representing more than 20% of pediatric surgical care for several conditions, nonoperative management is an understudied aspect of care with significant variation that warrants further research., Level of Evidence: III., (Copyright © 2019. Published by Elsevier Inc.)

Background: A previously implemented Enhanced Recovery Protocol (ERP) for children undergoing elective gastrointestinal operations demonstrated decreased length of stay (LOS) and in-hospital opioid use. We hypothesized that the ERP would be associated with decreased postdischarge opioid prescribing., Methods: Demographic, operative, and opioid prescription data were retrospectively compared between elective gastrointestinal surgical patients in the pre-ERP (1/2012-12/2014) and the post-ERP periods (1/2015-12/2017)., Results: Of the 99 patients reviewed, 56 (56.7%) were treated in the post-ERP era. Overall, 48 (48.5%) were male, and the most common operation was partial or total colectomy (n = 39, 39.4%) followed by ileocecectomy (n = 26, 26.3%). Most patients were 15-16 years of age and had inflammatory bowel disease (n = 88, 88.9%). LOS decreased from a median 4 days pre-ERP to 3 days post-ERP (p = 0.02). Patients receiving intraoperative opioids decreased from 100% to 46% (p < 0.01) and postoperative opioids from 95% to 59% (p < 0.01). Patients receiving an opioid prescription at discharge decreased from 69.8% pre-ERP to 30.9% post-ERP (p < 0.01). Among patients prescribed opioids at discharge, the number of doses (median 23 to 17, p = 0.44) and the median morphine equivalents/kg remained stable (median 2.3 to 1.7, p = 0.10)., Conclusions: A pediatric gastrointestinal surgery ERP resulted in decreased postdischarge prescribing of opioids., Type of Study: Retrospective cohort study., Level of Evidence: Level II., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Purpose: The aim of this study was to determine long-term outcomes for congenital diaphragmatic hernia (CDH) patients including quality of life (QoL), symptom burden, reoperation rates, and health status., Methods: A chart review and phone QoL survey were performed for patients who underwent CDH repair between 2007 and 2014 at a tertiary free-standing children's hospital. Comprehensive outcomes were collected including subsequent operations and health status. Associations with QoL were tested using Wilcoxon Rank-Sum tests and Pearson correlation coefficients., Results: Of 102 CDH patients identified, 46 (45.1%) patient guardians agreed to participate with mean patient age of 5.8 (SD, 2.2) years at time of follow-up. Median PedsQL TM and PedsQL TM Gastrointestinal scores were 91.8 (IQR, 84.8-95.8) and 95.8 (IQR, 93.0-98.2), out of 100. Thoracoscopic repair was associated with higher PedsQL TM scores while defects with an intrathoracic stomach were associated with increased gas and bloating. No difference in QoL was found when comparing defect side, patch vs primary repair, prenatal diagnosis, extracorporeal membrane oxygenation, or recurrence. Older age weakly correlated with worse school functioning and heartburn., Conclusion: Children with CDH have reassuring QoL scores. Given the correlation between older age and poor school function, longer follow-up of patients with CDH may be warranted., Level of Evidence: III (Retrospective comparative study)., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objectives: The evolving role of children's hospitals (CHs) in the setting of rising health care costs has not been fully explored. We compared pediatric inpatient discharge volumes and costs by hospital type and examined the impact of care complexity and hospital-level factors on costs., Methods: A retrospective, cross-sectional study of care between 2000 and 2009 was performed by using the Kids' Inpatient Database. Weighted discharge data were used to generate national estimates for a comparison of inpatient volume, cost, and complexity at CHs and nonchildren's hospitals (NCHs). Linear regression was used to assess how complexity, payer mix, and hospital-level characteristics affected inflation-adjusted costs., Results: Between 2000 and 2009, the number of discharges per 1000 children increased from 6.3 to 7.7 at CHs and dropped from 55.4 to 53.3 at NCHs. The proportion of discharges at CHs grew by 6.8% between 2006 and 2009 alone. In 2009, CHs were responsible for 12.6% (95% confidence interval: 10.4%-14.9%) of pediatric discharges and 14.7% of major therapeutic procedures, yet they accounted for 23.0% of inpatient costs. Costs per discharge were significantly higher at CHs than at NCHs for all years ( P < .001); however, the increase in costs seen over time was not significant. Care complexity increased during the study period at both CHs and NCH, but it could not be used to fully account for the difference in costs., Conclusions: National trends reveal a small rise in both the proportion of inpatient discharges and the hospital costs at CHs, with costs being significantly higher at CHs than at NCHs. Research into factors influencing costs and the role of CHs is needed to inform policy and contain costs., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2018 by the American Academy of Pediatrics.)

Purpose: The purpose of this study was to implement a novel surgeon-reported categorization (SRC) for pediatric appendicitis severity and determine if SRC was associated with outcomes., Methods: We conducted a retrospective review of appendectomies by 15 surgeons within a single center from January to December 2016. The SRC was defined as: simple (category 1), gangrenous or adherent (category 2A), perforation with localized abscess (category 2B), and perforation with gross contamination (category 2C). Logistic regression modeled the surgical site infections (SSI) and returns to the system. Cox proportional hazards analyses modeled the length of stay (LOS)., Results: The cohort included 697 patients (mean age 10.7 years). Compliance with SRC documentation increased from 33.5 to 85.9%. Review of operative findings revealed 100% concordance with SRC. The combined morbidity (SSI and revisits) rate was 9.8%. Category 2C patients had the highest odds of SSI (odds ratio 3.37 95% confidence interval 1.07-10.59). Median LOS increased with each category (category 1 = 1d, category 2A = 2d, category 2B = 4d, category 2C = 6d). When modeling intra-abdominal abscess, SRC displayed an improved model calibration and discrimination compared to wound class., Conclusion: SRC implementation is feasible and provides a granular assessment of appendicitis severity and outcomes. SRC may guide future quality improvement through development of grade-specific care pathways.

Purpose: Though growth in children's surgical expenditures has been documented, procedure-specific differences in volume and costs at children's hospitals (CH) and non-hildren's hospitals (NCH) have not been explored. Our purpose was to compare trends in volume and costs of common pediatric surgical procedures between CH and NCH., Methods: We performed a review of the 2000-2009 Kids' Inpatient Database identifying all cases of appendectomy for uncomplicated appendicitis (AP), tonsillectomy and adenoidectomy (TA), fundoplication (FP), humeral fracture repair (HFR), pyloromyotomy (PYL), and cholecystectomy (CHOLE). Trends in case volume and costs were examined at CH versus NCH., Results: The proportion of surgical care at CH increased for all procedures from 2000 to 2009. TA and CHOLE demonstrated higher costs per case at CH. Positive growth over time in cost per case at CH was seen for AP and FP, with the cost per case of FP increasing by 21% between 2006 and 2009., Conclusions: The proportion of surgeries performed at CH is continuing to grow alongside proportionate increases in costs, however costs for certain procedures are higher at CH than NCH. Further investigation is needed to explore cost containment at CH while still maintaining specialized, high quality surgical care., Level of Evidence: Level III., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Our goal is to determine short- and long-term outcomes of simple gastroschisis (SG) and complicated gastroschisis (CG) patients including quality of life (QoL) measures, surgical reoperation rates, and residual gastrointestinal symptom burden., Materials and Methods: Retrospective chart review of patients who underwent surgical repair of gastroschisis between January 1, 2009, and December 31, 2012, was performed at a quaternary children's hospital. Parent telephone surveys were conducted to collect information on subsequent operations and current health status as well as to assess QoL using two validated tools., Results: Of 143 patients identified, 45 (31.5%) were reached and agreed to participate with a median follow-up age of 4.7 y. Although CG was associated with short-term outcomes such as longer length of stay, longer days to feeds, and higher complication rates, there were no major differences in long-term QoL outcomes when comparing SG and CG. Children with CG experienced abdominal pain/gas/diarrhea more often than those with SG and required more major abdominal procedures than those with SG (15% versus 0%, P = 0.009)., Conclusions: Despite worse short-term outcomes, presence of certain gastrointestinal symptoms, and need for more surgical interventions for patients with CG, and overall QoL scores were reassuringly similar to those with SG., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Purpose: The appearance of the diaphragmatic curvature and the rib insertion level of the diaphragm on postoperative chest X-ray (CXR) may predict recurrence. Our purpose was to examine the relationship between the curvature of the diaphragm on postoperative CXR and recurrence., Methods: We performed a retrospective review of left-sided, Bochdalek congenital diaphragmatic hernia (CDH) surgical repairs from 2004 to 2015 at a single institution. We developed a tool to measure the flatness of the diaphragm on postoperative CXR, termed the diaphragmatic curvature index (τ). The primary outcome of interest was recurrence after surgical repair., Results: Of the 127 patients identified, 54% (n = 69) had a primary repair, while 46% (n = 58) required a patch repair. The overall recurrence rate was 21.3% (n = 27). There was no difference in median lateral rib insertion level in patients with and without recurrence or those who had a primary or patch repair. The overall median diaphragmatic curvature index was 6.29 (interquartile range [IQR] 5.30-8.09) and was not significantly different among patients who had a recurrence (6.00, IQR 5.34-8.24) and those who did not (6.46, IQR 5.24-8.07) (P = .853). Within the primary repair group (6.34 versus 6.93, P = .84) and the patch repair group (5.59 versus 6.18, P = .46), the median diaphragmatic curvature index was not different among patients who had a recurrence and those who did not., Conclusions: A flat appearance of the diaphragm on postoperative CXR as measured by the median diaphragmatic curvature index (τ) is not associated with recurrence. The shape of the diaphragm on CXR after CDH repair may not be predictive of recurrence as previously thought.

Purpose: Despite Enhanced Recovery After Surgery (ERAS) protocols demonstrating improved outcomes in a wide variety of adult surgical populations, these protocols are infrequently and inconsistently being used in pediatric surgery. Our purpose was to develop a pediatric-specific ERAS protocol for use in adolescents undergoing elective intestinal procedures., Methods: A modified Delphi process including extensive literature review, iterative rounds of surveys, and expert panel discussions was used to establish ERAS elements that would be appropriate for children. The 16-member multidisciplinary expert panel included surgeons, gastroenterologists, anesthesiologists, nursing, and patient/family representatives., Results: Building upon a national survey of surgeons in which 14 of 21 adult ERAS elements were considered acceptable for use in children, the 7 more contentious elements were investigated using the modified Delphi process. In final ranking, 5 of the 7 controversial elements were deemed appropriate for inclusion in a pediatric ERAS protocol. Routine use of insulin to treat hyperglycemia and avoidance of mechanical bowel preparation were not included in the final recommendations., Conclusions: Using a modified Delphi process, we have defined an appropriate ERAS protocol comprised of 19 elements for use in adolescents undergoing elective intestinal surgery. Prospective validation studies of ERAS protocols in children are needed., Level of Evidence: Level V, Expert opinion., (Copyright © 2017. Published by Elsevier Inc.)

Purpose: Enhanced recovery protocols (ERPs) have been shown to improve outcomes in adult surgical populations. Our purpose was to compare outcomes before and after implementation of an ERP in children undergoing elective colorectal surgery., Methods: A pediatric-specific colorectal ERP was developed and implemented at a single center starting in January 2015. A retrospective review was performed including 43 patients in the pre-ERP period (2012-2014) and 36 patients in the post-ERP period (2015-2016). Outcomes of interest included number of ERP interventions received, length of stay (LOS), complications, and readmissions., Results: The median number of ERP interventions received per patient increased from 5 to 11 from 2012 to 2016. The median LOS decreased from 5days to 3days in the post-ERP period (p=0.01). We observed a simultaneous decrease in median time to regular diet, mean dose of narcotics, and mean volume of intraoperative fluids (p<0.001). The complication rate (21% vs. 17%, p=0.85) and 30-day readmission rate (23% vs. 11%, p=0.63) were not significantly different in the pre- and post-ERP periods., Conclusions: Implementation of a pediatric-specific ERP in children undergoing colorectal surgery is feasible, safe and may lead to improved outcomes. Further experience may highlight other opportunities for increased compliance and improved care., Level of Evidence: Treatment Study. Level III., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Purpose: Enhanced Recovery After Surgery (ERAS) protocols have been shown to improve outcomes in adult abdominal surgical populations. Our purpose was to survey pediatric surgeons' opinions regarding applicability of individual ERAS elements to children's surgery., Methods: A survey of the American Pediatric Surgical Association was conducted electronically. Using a 5-point Likert scale, respondents rated their willingness to implement 21 adult ERAS elements in an adolescent undergoing elective colorectal surgery., Results: Of an estimated 1052 members, 257 completed the survey (24%). The majority of the respondents (n=175, 68.4%) rated their familiarity with ERAS as "moderately", "very", or "extremely familiar". However only 19.2% (n=49) replied that they were "already implementing" an ERAS protocol in their practice. Most respondents replied that they were "already doing" or "definitely willing" to implement 14 of the 21 (67%) ERAS elements. For the remaining 7 elements, >10% of surgeons answered that they were only "somewhat willing" to, "uncertain" about or "unwilling" to implement these interventions., Conclusions: Most respondents were willing to implement the majority of adult ERAS concepts in children undergoing abdominal surgery. However, we identified 7 elements that remain contentious. Further investigation regarding the safety and feasibility of these elements is warranted before applying them to children's surgery., Level of Evidence: Level V., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Introduction: Prolonged operative time (OT) is considered a reflection of procedural complexity and may be associated with poor outcomes. Our purpose was to explore the association between prolonged OT and complications in children's surgery., Methods: 182,857 cases from the 2012-2014 NSQIP-Pediatric were organized into 33 groups. OT for each group was analyzed by quartile, and regression models were used to determine the relationship between prolonged OT and complications., Results: Variations in OT existed for both short and long procedures. Cases in the longest quartile had twice the odds of postoperative complications after adjusting for age, sex and BMI (OR 1.85; 95% CI 1.78-1.91). Procedure-specific prolonged OT was associated with postoperative complications for the majority (85%) of procedural groupings. Prolonged OT was associated with minor complications in gynecologic (OR 4.17; 95% CI 2.19-7.96), urologic (OR 2.88; 95% CI 2.40-3.44), and appendix procedures (OR 2.88; 95% CI 2.49-3.34). There were increased odds of major complications in foregut (OR 6.56; 95% CI 4.99-8.64), gynecologic (OR 3.07; 95% CI 1.84-5.13), and spine procedures (OR 2.99; 95% CI 2.57-3.28)., Conclusions: Prolonged OT is associated with increased odds of postoperative complications across a spectrum of children's surgical procedures. Factors contributing to prolonged OT merit further investigation and may serve as a target for future quality improvement., Level of Evidence: Level III., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Surgeons balance competing interests of minimizing duration of stay with readmissions. Complications that occur early after discharge often result in readmissions. This study examines the relationship between duration of stay, timing of complications, and readmission risk., Methods: Cases from the 2012-2014 National Surgical Quality Improvement Project-Pediatric were organized into 30 procedural groups. Procedures where duration of stay approximated the median day of complication were identified. A theoretical model was applied to minimize readmissions by extending duration of stay., Results: From 30 procedure groups, 3 were identified where duration of stay approximated median day of compilations: complicated appendectomy, antireflux operation, and abdominal operation without bowel resection. The complicated appendectomy readmission rate drops from 12.2% to 8.2%, increasing duration of stay from 3 to 8 days at the cost of 16,428 additional hospital days among 4,740 patients (3.5 days/patient). Readmission optimization tapers after duration of stay of 8 days. Similar findings were observed for antireflux operation and abdominal operation without bowel resection with readmission optimization at duration of stay of 5 days (2.6 days/patient) and 7 days (5.3 days/patient), respectively., Conclusion: Our theoretical model aimed at balancing readmissions by extending duration of stay to capture early complications results in a substantial increase in hospital days illustrating the conflict between competing quality metrics and limited resources., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: While trends in perforated appendicitis (PA) rates have been studied, regional variability in pediatric admissions for PA remains unknown., Methods: A retrospective, cross-sectional analysis of the 2006-2012 Kids' Inpatient Database was conducted to examine variation in PA admission rates by region of the United States and insurance status. PA rates were calculated and reported as per 1000 admissions in accordance with national quality measure specifications., Results: National PA rates per 1000 admissions for 2006, 2009, and 2012 were 313.9, 279.2, and 309.1, respectively. Similarly, all regions demonstrated a statistically significant decrease in PA rates between 2006 and 2009 (p<0.001), where the increase in rates between 2009 and 2012 was only statistically significant in the Midwest [Odds Ratio (OR) 1.07; 95% Confidence Interval (95%CI) 1.03-1.12] and West (OR 1.10; 95% CI 1.07-1.14). The Northeast consistently experienced the lowest PA rates. The odds of PA were highest among uninsured patients (OR 1.35; 95% CI 1.31-1.29). The South had the highest proportion of uninsured children, and these patients had the highest odds of perforation (OR 1.57; 95% CI 1.21-2.02)., Conclusions: For children with appendicitis, geographic region and insurance status appear to be associated with perforation upon presentation. Understanding regional variation in pediatric PA rates may inform health policymakers in the constantly evolving insurance coverage landscape., Levels of Evidence Rating: Level III Treatment Study - Retrospective comparative study of appendicitis presentation in children by region of the country., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Though uncommon in children, pediatric thyroid nodules carry a higher risk of malignancy than adult nodules. While fine-needle aspiration (FNA) has been well established as the initial diagnostic test in adults, it has been more slowly adopted in children. The purpose of this study was to examine the comparative cost of FNA versus initial diagnostic lobectomy (DL) in the pediatric patient with an ultrasound-confirmed thyroid nodule., Methods: A decision tree model was created using an adolescent with an asymptomatic thyroid nodule as the reference case. Probabilities were defined based on review of the pediatric and adult literature. Costs were determined from previous literature and the publicly available Medicare physician fee schedule. Tornado plot and sensitivity analyses were performed to assess sources of cost variation., Results: Using decision analysis, FNA was less costly than DL with an estimated cost of $2529 vs. $5680. Tornado analysis demonstrated that the probability of an initial indeterminate FNA result contributed most to cost variation. On sensitivity analysis, when probability of an indeterminate FNA result was increased to 35%, the maximum value found in the literature, FNA remained less costly. In Monte Carlo simulation set to 10,000 iterations, FNA was superior to DL in 74% of cases., Conclusions: In this theoretical model based on available literature and costs, FNA is less costly than DL for initial diagnostic workup of thyroid nodules in children. Securing resources to offer FNA in the work-up of thyroid nodules may be financially beneficial to hospitals and patients., Level of Evidence: Level 1 cost effectiveness study - using reasonable costs and alternatives used in study with values obtained from many studies, study used multi-way sensitivity analysis., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Despite the availability of objective tests, gastroesophageal reflux disease (GERD) diagnosis and management in infants remains controversial and highly variable. Our purpose was to characterize national variation in diagnostic testing and surgical utilization for infants with GERD., Methods: Using the Pediatric Health Information System, we identified infants <1 year old diagnosed with GERD between January 2011 and March 2015. Outcomes included progression to antireflux surgery (ARS) and use of relevant diagnostic testing. By using adjusted generalized linear mixed models, we compared facility-level ARS utilization., Results: Of 5 299 943 infants, 149 190 had GERD (2.9%), and 4518 (3.0%) of those patients underwent ARS. Although annual rates of GERD and ARS decreased, there was a wide range of GERD diagnoses (1.8%-6.2%) and utilization of ARS (0.2%-11.2%). Facilities varied in the use of laparoscopic versus open ARS (mean: 66%, range: 23%-97%). Variation in facility-level ARS rates persisted after adjustment. Overall 3.8% of patients underwent diagnostic testing, whereas 22.8% of ARS patients underwent diagnostic testing. The proportion of surgeries done laparoscopically was independently associated with ARS utilization (odds ratio: 1.57; 95% confidence interval: 1.21-2.02). Facility-level utilization of diagnostics ( P > .1) and prevalence of GERD ( P > .1) were not associated with utilization of ARS., Conclusions: There is notable variation in the overall utilization of ARS and in the surgical and diagnostic approach in infants with GERD. Fewer than 4% of infants with GERD undergo diagnostic testing. This variation in care merits development of consensus guidelines and further research., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2017 by the American Academy of Pediatrics.)

Objective: Our aim was to implement a standardized US report that included secondary signs of appendicitis (SS) to facilitate accurate diagnosis of appendicitis and decrease the use of computed tomography (CT) and admissions for observation., Methods: A multidisciplinary team implemented a quality improvement (QI) intervention in the form of a standardized US report and provided stakeholders with monthly feedback. Outcomes including report compliance, CT use, and observation admissions were compared pretemplate and posttemplate., Results: We identified 387 patients in the pretemplate period and 483 patients in the posttemplate period. In the posttemplate period, the reporting of SS increased from 5.4% to 79.5% (p<0.001). Despite lower rates of appendix visualization (43.9% to 32.7%, p<0.001) with US, overall CT use (8.5% vs 7.0%, p=0.41) and the negative appendectomy rate remained stable (1.0% vs 1.0%, p=1.0). CT utilization for patients with an equivocal ultrasound and SS present decreased (36.4% vs 8.9%, p=0.002) and admissions for observations decreased (21.5% vs 15.3%, p=0.02). Test characteristics of RLQ US for appendicitis also improved in the posttemplate period., Conclusion: A focused QI initiative led to high compliance rates of utilizing the standardized US report and resulted in lower CT use and fewer admissions for observation. Study of a Diagnostic Test Level of Evidence: 1., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: There is significant variation surrounding the indications, surgical approaches, and outcomes for children undergoing antireflux procedures (ARPs) resulting in geographic variation of care. Our purpose was to quantify this geographic variation in the utilization of ARPs in children., Methods: A cross-sectional analysis of the 2009 Kid's Inpatient Database was performed to identify patients with gastroesophageal reflux disease or associated diagnoses. Regional surgical utilization rates were determined, and a mixed effects model was used to identify factors associated with the use of ARPs., Results: Of the 148,959 patients with a diagnosis of interest, 4848 (3.3%) underwent an ARP with 2376 (49%) undergoing a laparoscopic procedure. The Northeast (2.0%) and Midwest (2.2%) had the lowest overall utilization of surgery, compared with the South (3.3%) and West (3.4%). After adjustment for age, case-mix, and surgical approach, variation persisted with the West and the South demonstrating almost two times the odds of undergoing an ARP compared with the Northeast. Surgical utilization rates are independent of state-level volume with some of the highest case volume states having surgical utilization rates below the national rate. In the West, the use of laparoscopy correlated with overall utilization of surgery, whereas surgical approach was not correlated with ARP use in the South., Conclusions: Significant regional variation in ARP utilization exists that cannot be explained entirely by differences in patient age, race/ethnicity, case-mix, and surgical approach. In order to decrease variation in care, further research is warranted to establish consensus guidelines regarding indications for the use ARPs for children., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Infants with congenital cardiac disease (CCD) often require gastrostomy tube placement (GT) and need antireflux procedures, such as fundoplications. Our purpose was to compare morbidity/mortality rates among infants with CCD undergoing GT, fundoplication, or both., Methods: Using the NSQIP-Pediatric, we identified 4070 patients <1-year-old who underwent GT and/or fundoplication from 2012 to 2014. 2346 infants (58%) had CCD categorized as minor, major or severe. Regression models were used to estimate the association of CCD with morbidity/mortality., Results: Among all patients undergoing fundoplication, there were increased odds of morbidity/mortality among CCD patients compared to non-CCD patients (OR 2.15; p < 0.001). Odds of complications decreased when procedures were performed laparoscopically or later in the first year of life. Using GT alone as a reference, fundoplication alone (OR 1.67; p < 0.001) and GT with fundoplication (OR 1.82; p < 0.001) had increased odds of morbidity/mortality among cardiac patients. Increased risk persisted after stratification by severity of CCD and after accounting for surgical approach., Conclusion: Fundoplication is associated with increased odds of morbidity/mortality in infants with CCD compared to GT alone. Risks are lower with laparoscopic approach and if surgery is delayed until later in the first year of life. Timing and surgical approach for patients with CCD requires further investigation.

Purpose: Accidental puncture or laceration (APL) has been endorsed as a patient safety indicator and is being used to compare hospital performance and for reimbursement. We sought to determine the positive predictive value (PPV) of APL as a quality metric in a pediatric population., Methods: We retrospectively reviewed all cases that met APL administrative criteria over 5years in a quaternary pediatric hospital system. Events were categorized as false positive (FP) or true positive (TP). TP cases were further categorized as "potentially consequential" or "inconsequential". The PPV of APL was calculated, and a z-test was used to provide 95% confidence intervals., Results: Of the 238 cases identified, 204 were categorized as TP (86%; 95% CI: 80%-90%). Thirty-four of these events (17%) involved injuries that were considered "inconsequential". True events that required repair were identified as "potentially consequential" (n=170). Thus, the PPV of APL was 71% (95% CI: 65%-77%). Extenuating factors such as adhesive disease or abnormal anatomy were present in 39% of TP cases. Thirty-four cases (14%) were categorized as FP because no documented injury was found., Conclusions: A large proportion of APL events are either false or clinically irrelevant, thus questioning its usability as a patient safety indicator for children undergoing surgery., Type of Study: Retrospective review., Level of Evidence: IV., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Postprocedural revisits, readmissions, and reoperations are commonly tracked quality metrics and have reimbursement and hospital-level comparison implications. Our purpose was to document these rates after pediatric appendectomy and to identify patient factors related to these metrics. This study included 3756 appendectomies performed at a single institution from 2009 to 2013. Data were prospectively collected and clinical events within 30 days of discharge were analyzed. Regression models identified factors associated with each metric. There were 328 returns to the emergency department (8.7%), 128 readmissions (3.4%), and 41 reoperations (1.0%). The main source of readmission was the emergency department (n = 118, 92%). Nearly two-thirds of readmissions were nonoperative (n = 87, 68%) and 12.5 per cent of readmissions were not related to the index appendectomy. Factors associated with readmission include procedure length >70 minutes [odds ratio (OR) 1.89, P = 0.043] and failed nonoperative management of perforated appendicitis (OR 2.97, P = 0.041). The most common indication for reoperation was intra-abdominal abscess (n = 20, 49%), 55 per cent of which were managed with image-guided drainage. In conclusion, although 30-day revisit, readmission, and reoperation rates after appendectomy are low, there are opportunities for improvement. Furthermore, many 30-day readmissions are not related to the index procedure and must be clearly identified to avoid inaccuracies with reimbursement and quality rankings.

Background: Enhanced recovery after surgery (ERAS), guidelines entail a strategy of perioperative management proven to hasten postoperative recovery and reduce complications in adult populations. Relatively few studies have investigated the applicability of this paradigm to pediatric populations. Our objective was to perform a systematic review of existing evidence regarding the use and efficacy of enhanced recovery protocols (ERPs) in the pediatric population., Materials and Methods: Data were collected through a PubMed/MEDLINE literature search. Study eligibility criteria included a pediatric population and implementation of at least four components of published ERAS Society recommendations., Results: One retrospective and four prospective cohort studies evaluating children undergoing gastrointestinal, urologic, and thoracic surgeries were identified. The overall quality of reporting was fair with few studies acknowledging limitations and bias and inconsistent outcome reporting. Studies included six or fewer interventions compared to 20 recommended interventions in most adult ERAS Society guidelines. None of the studies were well controlled. Nevertheless, these studies suggest that ERPs applied to the appropriate pediatric surgical populations may be associated with decreased length of stay, decreased narcotic use, and no detectable increase in complications., Conclusions: There is a paucity of high-quality literature evaluating implementation of ERPs in pediatric populations. The limited literature available indicates that ERPs would be safe and potentially effective. More studies are needed to assess the efficacy of ERPs in pediatric surgery., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: This study explores the perceived volume of women affected by peri- or post-menopausal issues that present to primary care clinicians in West Cheshire, plus the self-reported confidence of those clinicians in managing the menopause, and whether or not they feel that they and their patients should have access to a specialist menopause service., Study Design: Completion of an electronic survey., Population: General practitioners and practice nurses working in West Cheshire., Main Outcome Measure: To provide evidence for future local commissioning of menopause services., Results: Ninety-one clinicians working within West Cheshire were sent an email request to complete the survey with 53 responses received (58%). The majority were general practitioners and were within the 35-54 year age range. The majority perceived that, each week in their clinical practice, they see between one and eight women who are affected by peri- or post-menopausal symptoms. Regarding their self-reported skills and knowledge in managing the menopause, almost half felt they had 'good' knowledge but 'recognised (they) had learning needs'. Seven of the 53 (13%) felt their skills were 'not good'. Two-thirds of those clinicians who completed the survey felt that they and their patients should have access to a specialist menopause service locally., Conclusions: In the area covered by West Cheshire clinical commissioning group, there is no currently commissioned menopause service. This study has demonstrated that a substantial number of women present each week to clinicians working in this area who are felt to have peri- or post-menopausal symptoms. The clinicians have self-reported learning needs. Qualitative data from the survey would suggest training can be difficult to access. There is a clear need, both ethically and medically, for the commissioning of a West Cheshire specialist menopause service, with the proposed model being an integrated and holistic care model. Menopause care, and post-reproductive healthcare generally, provides an opportunity for collaboration and partnership working within an outcomes-based commissioning model. This study could be reviewed and replicated in other areas for comparison., (© The Author(s) 2015.)