The Impact of Payer Source on Trauma Outcomes in a Pediatric Population.

OBJECTIVES: Determine if there were differences in conclusions drawn regarding disparities in trauma outcomes based on literature-derived payer source definitions in a pediatric population. PATIENTS AND METHODS: Retrospective registry review of admitted pediatric trauma patients (≤17 years of age) at a level II pediatric trauma facility. Eligible patients were categorized into 3 payer source definitions: definition 1: commercially insured, Medicaid, uninsured; definition 2: insured, uninsured; definition 3: commercially insured, underinsured. Logistic regression was used to determine the influence of payer source on outcomes. RESULTS: Payer source was not significant in definition 1, 2, or 3 for intensive care unit length of stay (LOS), hospital LOS, medical consults, or mortality. For hospital disposition, payer source was significant in definition 1, the uninsured were 90% less likely than commercially insured to be discharged to continued care. In definition 2, the uninsured were 88% less likely than insured to be discharged to continued care. In definition 3, the underinsured were 57% less likely than commercially insured to be discharged to continued care. CONCLUSIONS: Differences between the literature-derived definitions were not observed and therefore conclusions drawn did not differ across definitions. The investigation demonstrated payer source was not associated with in-hospital outcomes (intensive care unit LOS, hospital LOS, medical consults, and mortality), but was with posthospital outcomes. Findings warrant future examinations on the categorization of payer source in pediatric patients and hospital disposition to gain a greater understanding of disparities related to payer source in pediatric trauma, specifically in terms of posthospital care.

Influence of extracorporeal membrane oxygenation on subsequent surgeries after congenital diaphragmatic hernia repair.

PURPOSE: Congenital diaphragmatic hernia (CDH) is a complex anomaly requiring intensive pulmonary and hemodynamic management. Survival has increased in this population placing them at risk for subsequent morbidities including surgery. The purpose of this study is to review the need for subsequent surgeries in the CDH population. METHODS: After receiving institutional review board approval, a retrospective chart review of all CDH patients between 1980 and 2007 was conducted noting subsequent surgeries and the impact of extracorporeal membrane oxygenation (ECMO) on the types of surgical procedures. Comparison of groups was done by Fisher's Exact test or nonparametric Wilcoxon rank-sum test where appropriate. A P value of less than .05 was considered significant. RESULTS: Data were analyzed for 227 of 294 patients during this period. Extracorporeal membrane oxygenation support was used in 45% of patients. Subsequent surgery was required in 117 patients. Seventy patients in the ECMO group (69%) required a subsequent operation. The most common operative procedures included inguinal hernia/orchiopexy, antireflux, and recurrent diaphragmatic hernias. CONCLUSION: In this series, ECMO survivors are at a high risk for requiring subsequent surgeries compared to the total CDH group. This information can be used as an education tool for referring physicians and parents as they care for this group of children.

Appendicitis in childhood hematologic malignancies: analysis and comparison with typhilitis.

BACKGROUND/PURPOSE: Recognition of appendicitis in the child with hematologic malignancy may be difficult particularly in the setting of neutropenia and multiple medications causing an altered inflammatory response. Typhilitis may produce a similar constellation of clinical findings causing further diagnostic confusion. This review compares the relative frequency of these two conditions in children with hematologic malignancy with a focus on the clinical presentation, distinguishing features, surgical management, and outcome for patients with appendicitis. METHODS: This institutional review board-approved retrospective study evaluated 464 pediatric patients treated for hematologic malignancy at our institution from 1997 to 2003. From this cohort, we identified all children with a diagnosis of appendicitis or typhilitis. Data include demographics, clinical presentation, laboratory studies, and computed tomography (CT) scan findings. Groups were compared using the Fisher exact test. Significance was defined as P < .05. RESULTS: Eight (1.7%) of 464 children were diagnosed with typhilitis and 7 (1.5%) with appendicitis. There were no demographic differences between patients with appendicitis and typhilitis. Distinguishing clinical features in children with typhilitis included presence of fever and diarrhea. Clinical presentation in children with appendicitis was atypical in 5 of 7 cases yielding an incorrect preoperative diagnosis in all 5. Radiographic evaluation by CT scan accurately defined typhilitis, but not appendicitis. An operation was performed on all 7 children with appendicitis with no operative morbidity or mortality. CONCLUSIONS: Appendicitis and typhilitis occur with similar frequency in children with leukemia and lymphoma. Typhilitis is accurately diagnosed with clinical findings of fever, diarrhea, abdominal pain, and typical CT scan findings. Appendicitis tends to present with atypical findings, but can be successfully managed with standard surgical care.