Lessons learned from value-based pediatric appendectomy care: A shared savings pilot model.

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.

Thyroid surgery outcomes at a children's hospital: The value of a multidisciplinary team approach.

BACKGROUND: Our purpose is to describe the structure, function and outcomes of our multidisciplinary pediatric thyroid program and to evaluate our experience in comparison to other high-volume centers. METHODS: We reviewed all thyroid operations performed 10/2012 through 09/2019, and examined number of cases per year, patient demographics, procedures, final diagnoses and results. Primary outcomes were hypoparathyroidism and recurrent laryngeal nerve (RLN) injury at 12 months. Data were analyzed using descriptive statistics and univariate analyses. RESULTS: We performed 294 thyroid operations on 279 patients. Seventy-nine percent were female. Median age was 15 years (IQR: 12-17). Operations included total thyroidectomy (65%), lobectomy (30%) and completion thyroidectomy (5%). Most common diagnoses were Graves' disease (35%), malignancy (29%), and benign nodule (20%). We developed an evidence-based clinical pathway and conducted weekly multidisciplinary meetings. A clinical data specialist reviewed process and outcome measures routinely. Overall, 6 patients (2.0%) had hypoparathyroidism and 2 (0.7%) had unilateral RLN injury at 12 months. Two of the patients with clinical suspicion of permanent hypoparathyroidism were ultimately weaned off calcium. Both patients with RLN injury had extensive locally advanced malignant disease involving the nerve. CONCLUSIONS: Our multidisciplinary team achieved excellent long-term outcomes for pediatric thyroid surgery comparable to other high-volume pediatric and adult centers.

Quantifying the effect of resident education on outcomes in pediatric appendicitis.

BACKGROUND/PURPOSE: Surgical residents are involved in the care of patients in a climate where quality of care is an important outcome measure. The purpose of this study was to evaluate the effect of resident involvement on appendectomy outcomes. METHODS: We retrospectively reviewed appendectomies, ages 0-18, from January 2016 to December 2018. Operative time, operative charges, and postoperative outcomes were evaluated for cases with and without a resident. Data were analyzed using Wilcoxon rank and Fisher's exact tests. RESULTS: Of 1842 appendectomies (1267 resident present and 575 no resident present), there was no difference in postoperative stay, abscess formation, readmission, or emergency room visits for simple or complex appendicitis. Operative time was significantly longer for cases of simple appendicitis by 10 min (p = <0.0001) and charges significantly higher by $600 (p = <0.0001) when a resident was involved in the case. These differences held true for complex appendicitis (time longer by 9 min, p = <0.0001 and charges higher by $500, p = 0.03). CONCLUSION: Resident involvement results in an increase in operative time and charges, with no difference in length of stay or complications. These results highlight the cost of resident involvement, without an increase in complications experienced by patients. LEVEL OF EVIDENCE: Level III evidence.