Search

Purpose We aim to assess the healthcare value achieved from a shared savings program for pediatric appendectomy. Methods All appendectomy patients covered by our health plan were included. Quality targets were 15% reduction in time to surgery, length of stay, readmission rate, and patient satisfaction. Quality targets and costs for an appendectomy episode in two 6-month performance periods (PP1, PP2) were compared to baseline. Results 640 patients were included (baseline:317, PP1:167, PP2:156). No quality targets were met in PP1. Two quality targets were met during PP2: readmission rate (−57%) and patient satisfaction. No savings were realized because the cost reduction threshold (−9%) was not met during PP1 (+1.7%) or PP2 (−0.4%). Conclusions Payer-provider partnerships can be a platform for testing value-based reimbursement models. Setting achievable targets, identifying affectable quality metrics, considering case mix index, and allowing sufficient time for interventions to generate cost savings should be considered in future programs.

INTRODUCTION Studies have shown the benefit of intensive care unit (ICU) bundled protocols; however, they are primarily derived from medical patients. We hypothesized that patients and their medication profiles are different between critically ill medical, surgical, and trauma patients. METHODS The Pediatric Health Information System 2017 dataset was used to perform a retrospective cohort study of critically ill children. The pediatric medical, surgical, and trauma cohorts were separated based on ICD-10 codes. Data collected included demographics, secondary diagnoses, outcomes, and medication data. Medications were grouped as opiates, GABA-agonists, alpha-2 agonists, anti-psychotics, paralytics, and "other" sedatives. A non-parametric Kolmogorov-Smirnov test (KS test) and odds ratios (reference group: medical cohort) were calculated to compare medication administration between the study cohorts for the first 30 ICU days. RESULTS A total of 4488 critically ill children (medical 2078, surgical 1650, and trauma 760) were identified. The trauma cohort had increased incidence of delirium (medical 10.8%, surgical 11.5%, trauma 13.8%; p 50% received GABA-agonists on ICU days 0-30. With the KS test, there was a significant difference in administration of opiates, GABA-agonists, alpha-2 agonists, anti-psychotics, and "other" sedatives over the first 30 days in the ICU. Relative to medical patients, trauma patients had significantly higher odds of receiving anti-psychotics on ICU days 10-20 and 22-24. CONCLUSION Critically ill pediatric trauma, medical, and surgical patients are distinctly different patient populations with differing pharmacologic profiles for analgesia, sedation, and delirium. LEVEL OF EVIDENCE Level III (Retrospective Comparative Study).

SARS-CoV-2 has profoundly affected the way healthcare is delivered and has created significant strain on medical facilities globally. As a result, hospitals have had to continuously adapt in order to provide optimal patient care while minimizing the risk of SARS-CoV-2 transmission, particularly in the surgical setting. Texas Children's Hospital developed a set of protocols for surgical screening and clearance of patients in the context of the COVID-19 pandemic. These screening protocols were designed to mitigate the risk of exposing patients and healthcare providers to SARS-CoV-2 and have evolved significantly as a result of the emerging changes in medicine, technology, and governmental regulations. In this article, we share the reasoning behind the development, implementation, and successive modification of our institutional screening protocols.

Introduction The Nuss procedure is the most common and preferred operative correction of pectus excavatum. Surgeon preference and patient factors can result in variations in Nuss procedure technique. We hypothesize that certain techniques are associated with increased risk of complications. Materials and Methods We performed a single-center retrospective review of Nuss operations from 2016 to 2020. Variations in intraoperative techniques included sternal elevator (SE) use, number of bars placed, and usage of bilateral stabilizing sutures. Patient demographics, intraoperative data, and postoperative outcomes were reported as median with interquartile ranges or percentages. Statistical significance (p Results Two hundred and sixty-five patients were identified. Patients repaired with two bars were older with a larger Haller index (HI). Patient demographics were not significantly different for SE or stabilizing suture use. Placement of two bars was associated with significantly increased risk of readmission. Similarly, SE use was associated with increased risk of pleural effusion and readmission. Finally, the use of bilateral stabilizing sutures resulted in less frequent slipped bars without statistical significance. Conclusion Older patients with a larger HI were more likely to need two bars placed to repair pectus excavatum. Placement of multiple bars and SE use are associated with significantly higher odds of certain complications.

No consensus guidelines exist for timing of enterostomy closure in neonatal isolated intestinal perforation (IIP). This study evaluated neonates with IIP closed during the initial admission (A1) versus a separate admission (A2) comparing total length of stay and total hospital cost.Using 2012 to 2017 Pediatric Health information System (PHIS) data, 359 neonates with IIP were identified who underwent enterostomy creation and enterostomy closure. Two hundred sixty-five neonates (A1) underwent enterostomy creation and enterostomy closure during the same admission. Ninety-four neonates (A2) underwent enterostomy creation at initial admission and enterostomy closure during subsequent admission. For the A2 neonates, total hospital length of stay was calculated as the sum of hospital days for both admissions. A1 neonates were matched to A2 neonates in a 1:1 ratio using propensity score matching. Multivariate models were used to compare the two matched pair groups for length of stay and cost comparisons.Prior to matching, the basic demographics of our study population included a median birthweight of 960 g, mean gestational age of 29.5 weeks, and average age at admission of 4 days. Eighty-seven pairs of neonates with IIP were identified during the matching process. Neonates in A2 had 91% shorter total hospital length of stay compared to A1 neonates (HR: 1.91; 95% CI for HR: 1.44-2.53; p .0001). The median length of stay for A1 was 95 days (95% CI: 78-102 days) versus A2 length of stay of 67 days (95% CI: 56-76 days). Adjusting for the same covariates, A2 neonates had a 22% reduction in the average total cost compared A1 neonates (RR: 0.78; 95% CI for RR: 0.64-0.95; p-value = 0.014). The average total costs were $245,742.28 for A2 neonates vs. $315,052.21 for A1 neonates (p 0.001).Neonates with IIP have a 28 day shorter hospital length of stay, $75,000 or 24% lower total hospital costs, and a 22 day shorter post-operative course following enterostomy closure when enterostomy creation and closure is performed on separate admissions.Prognosis Study.Level II.

Background: Thoracic inlet (TI) tumors are rare, and can be particularly challenging to resect due to proximity to mediastinal vessels and nerves. Traditional resection is typically performed throu...

Extrarenal malignant rhabdoid tumors (MRT) are highly aggressive tumors of childhood with a poor overall prognosis. While most commonly found within the kidney and central nervous system, MRT can also occur in other locations and present highly specific challenges for pediatric surgical providers in an effort to achieve a meaningful resection. Cervical rhabdoid tumors are extremely rare. We report the multidisciplinary management of a patient with a complex cervicothoracic malignant rhabdoid tumor who underwent successful surgical resection with a greater than one year survival.

Purpose Ganglioneuroma (GN) and ganglioneuroblastoma-intermixed (GNB-I) represent benign variants of neuroblastic tumors in children; however, differentiating from more aggressive histological variants of GNB including the nodular subtype (GNB-N) prior to resection can be challenging, even with biopsy. Currently, no standard treatment guidelines exist. The purpose of this study was to identify pre-operative characteristics of benign neuroblastic tumors and evaluate outcomes for patients who underwent surgical resection or observation. Methods Retrospective chart review of children treated at a single institution between 2009 and 2019 for non-metastatic tumor with a tissue diagnosis of GN, GNB-N or GNB-I. Demographics, imaging, labs, operative details and outcomes were recorded and analyzed. Results Of 53 patients, 45% were male. The most common tumor location was abdomen (49%), followed by thorax (34%). Forty-five percent had at least one image defined risk factor. Biopsy was performed in 32% (17/53) and upfront surgery in 68% (36/53). Three patients (3/53, 5.6%) with biopsy demonstrating GN tumors were observed due to high surgical risk. Pathology of resected specimens demonstrated GN in 52% (26/50) and GNB-I or GNB-N in 48% (24/50). The majority of GNB tumors (75% (18/24) were GNB-I and 25% (6/24) were GNB-N. Therefore, 88% of the resected tumors were benign spectrum neuroblastic tumors (GN & GNB-I). Seven (7/50, 14%) patients experienced perioperative complication (temporary paralysis, Horner's syndrome, chylothorax, vocal cord paralysis). Recurrence was noted in 1 patient with GN (1/50, 2%) and 3 with GNB-N (3/50, 6%). There were no tumor-related deaths. Patients with GN were older than those with GNB (8.8 years (IQR 6–11.25) vs 5.6 years for GN (IQR 3–7); p = 0.01). GNB tumors were also more likely to have calcifications on imaging (63% vs. 38%, p = .01) and more commonly had MIBG avidity (88% vs 66%, p = .04). There were no significant differences in tumor size or symptoms at presentation. Conclusions In children with neuroblastic tumors, older age, CT without tumor calcifications, lack of MIBG avidity, and/or normal urine catecholamines may indicate benign GN. Close observation could be considered for asymptomatic patients meeting these criteria with biopsy-proven GN, with resection reserved for progressive growth or symptom development. However, larger, multicenter studies are needed for further validation. Level of evidence IV.

Background Recent studies have shown intercostal cryoablation(IC) during the Nuss procedure decreases hospital length of stay(LOS) and opioid administration. However, few studies have also evaluated the risk of postoperative complications related to IC. Methods We performed a single center retrospective analysis of all patients who underwent Nuss procedure by one surgeon from 2/2016 to 2/2020, comparing intraoperative IC to other pain management modalities(non-IC). Primary outcomes were postoperative complications, hospital LOS, and opioid administration. Multivariate analysis was performed with outcomes reported as regression coefficients(RC) or odds ratios(OR) with 95% confidence interval. Results IC was associated with decreased hospital LOS (RC −1.91[−2.29 to −1.54], less hospital opioid administration (RC −4.28[−5.13 to −3.43]), and less discharge opioid administration (RC −3.82[−5.23 to −2.41]). With respect to postoperative complications, IC decreased the odds of urinary retention (OR 0.16[0.06 to 0.44]); however, increased the odds of slipped bars requiring reoperation (OR 36.65[5.04–266.39]). Conclusions Our single surgeon experience controls for surgeon variability and demonstrates intraoperative IC for the Nuss procedure is an effective pain management modality that decreases hospital LOS and opioid use during hospitalization and at discharge; however, it is associated with increased odds of slipped bars requiring reoperation. Level of evidence III

Background Current literature has shown that adult patients with perioperative Coronavirus Disease-2019 (COVID-19) have increased rates of postoperative morbidity and mortality. We hypothesized that children with COVID-19 have favorable postoperative outcomes compared to the reported adult experience. Methods We performed a retrospective cohort study for children with a confirmed preoperative COVID-19 diagnosis from April 1st, 2020 to August 15th, 2020 at a free-standing children's hospital. Primary outcomes evaluated were postoperative complications, readmissions, reoperations, and mortality within 30 days of operation. Secondary outcomes included hospital resource utilization, hospital length of stay, and postoperative oxygen support. Results A total of 66 children with preoperative confirmed COVID-19 were evaluated with median age of 9.5 years (interquartile range (IQR) 5–14) with 65% male and 70% Hispanic White. Sixty-five percent of patients had no comorbidities, with abdominal pain identified as the most common preoperative symptom (65%). Twenty-three percent of patients presented with no COVID-19 related symptoms. Eighty-two percent of patients had no preoperative chest imaging and 98% of patients did not receive preoperative oxygen support. General pediatric surgeons performed the majority of procedures (68%) with the most common diagnosis appendicitis (47%). Forty-one percent of patients were discharged the same day as surgery with 9% of patients utilizing postoperative intensive care unit resources and only 5% receiving postoperative invasive mechanical ventilation. Postoperative complications (7%), readmission (6%), and reoperation (6%) were infrequent, with no mortality. Conclusion COVID-19+ children requiring surgery have a favorable postoperative course and short-term outcomes compared to the reported adult experience. Type of study Prognosis Study. Level of evidence Level IV.

Introduction: Trauma is the most common cause of death in the United States for those aged between 1 and 44 years.1 Blunt trauma encompasses >90% of all injuries to children.2 Specifically, blunt a...

There is no required competency for pediatric vascular injury in surgical training. We sought to describe changes over time for surgical specialists operating on pediatric vascular trauma injuries at a pediatric trauma center.Charts were retrospectively reviewed for vascular trauma injuries at a freestanding children's hospital between 1993 and 2015. Data were collected on mechanism, injured vessel(s), operation(s) performed, and specialists performing operation. Surgical specialists were compared over time.Ninety-four patients (median age = 12) underwent 101 pediatric vascular trauma operations. There were significant differences in frequency of types of operations (primary repairs, graft repairs, and ligations) performed by pediatric, vascular, and orthopedic surgeons (P.001). The proportion of operations performed by vascular surgeons increased and those performed by pediatric surgeons decreased significantly over time.Various surgical specialists manage pediatric vascular trauma. With expansion of integrated residency programs, surgical specialists managing these patients in the future should be trained in both pediatric and vascular surgery.

We report an infant with COVID-19 who presented with bloody stools, lethargy and imaging findings significant for pneumatosis intestinalis. The infant was treated with conservative therapy, including resuscitation, bowel rest and intravenous antibiotics, successfully avoiding surgical intervention.

Optimal timing to begin feeds in neonates with gastroschisis remains unclear. We examined if bedside abdominal ultrasound for intestinal motility is a feasible tool to detect return of bowel function in neonates with gastroschisis.Neonates born with uncomplicated gastroschisis who underwent closure received daily ultrasound exams. Full motility was defined as peristalsis seen in all quadrants. Average length of time between abdominal wall closure and start of enteral feeds, full ultrasound motility, and clinical characteristics was compared using Student's t-tests.Seventeen patients were enrolled. No differences were found between motility on ultrasound and bowel movements, gastric residuals, or nonbilious residuals. Mean time to enteral feeds (11.82days) was significantly delayed compared to documentation of full motility on ultrasound (8.94days; p=0.012), consistent bowel movements (8.41days; p=0.006), low gastric residuals (9.47days; p0.001), and nonbilious residuals (9.18days; p0.001). In the single subject in which feeds were started before full motility was seen on ultrasound, feeds were subsequently discontinued because of emesis.Bedside abdominal ultrasound provides real-time evidence regarding intestinal motility and is a feasible tool to detect return of bowel function in neonates with gastroschisis. Future studies are needed to determine if abdominal ultrasound can shorten time to start of enteral feeds.III (diagnosis: nonconsecutive study).

Background Both the Medicare (MCR) and Medicaid (MCD) programs turn 50 this year. Medicare has developed a national resource-based payment methodology for physicians' services, with broad input by specialty societies, and MCD payments are set by individual states by various means. Study Design We have conducted the first national comparison of payment methodology of MCD vs MCR for procedures commonly delivered by general surgeons. Using the most recent Centers for Medicare and Medicaid Services' Medicare data for frequency of allowed charges for general surgeons, we selected the most frequently billed procedures and gathered data from the 50 states for MCD and MCR payments. We determined the "Medicaid discount" (MCD payment minus MCR payment) expressed as dollars and percent, as well as dollars paid per relative value of work. Results We have discovered wide variations in MCD payments among states for the same procedures, demonstrating unexplained "discounts" of MCD payments in relationship to MCR. We found that MCD payments show wide variations across the states, with many states paying far less than MCR for common, essential procedures. Conclusions These findings call into question the fairness of MCD reimbursement for general surgery services in the United States. This discount to MCR could act as a disincentive for surgeons to care for some patients, based on the state of residence. These unexplained discounts could have considerable long-term effects for patients dependent on the MCD program. Our study should act as a stimulus for states to examine their payment methodologies to provide more uniform and fairer payments for surgical procedures.