Povidone-iodine intra-abdominal irrigation versus no irrigation in pediatric perforated appendicitis: A secondary economic analysis of a Bayesian randomized controlled trial.

BACKGROUND: A pilot randomized controlled trial (RCT) conducted in children (2-17 â€‹y) with perforated appendicitis demonstrated an 89% probability of reduced intra-abdominal abscess (IAA) rate with povidone-iodine (PVI) irrigation, compared with no irrigation (NI). We hypothesized that PVI also reduced 30-day hospital costs. METHODS: We conducted a retrospective economic analysis of a pilot RCT. Hospital costs, inflated to 2019 U.S. dollars, were obtained for index admissions and 30-day emergency visits and readmissions. Cost differences between groups were assessed using frequentist and Bayesian generalized linear models. RESULTS: We observed a 95% Bayesian probability that PVI reduced 30-day mean total hospital costs ($16,555 [PVI] versus $18,509 [NI]; Bayesian cost ratio: 0.90, 95% CrI, 0.78-1.03). The mean absolute difference per patient was $1,954 less with PVI (95% CI, -$4,288 to $379). CONCLUSIONS: PVI likely reduced the IAA rate and 30-day hospital costs, suggesting the intervention is both clinically superior and cost saving.

Costs associated with postoperative intra-abdominal abscess in pediatric perforated appendicitis: A retrospective cohort study.

BACKGROUND: Intra-abdominal abscess, the most common complication after perforated appendicitis, is associated with considerable economic burden. However, costs of intra-abdominal abscesses in children are unknown. We aimed to evaluate resource utilization and costs attributable to intra-abdominal abscess in pediatric perforated appendicitis. METHODS: A single-center retrospective analysis was performed of children (<18 years) who underwent appendectomy for perforated appendicitis (2013-2019). Hospital costs incurred during the index admission and within 30 postoperative days were obtained from the hospital accounting system and inflated to 2019 USD. Generalized linear models were used to determine excess resource utilization and costs attributable to intra-abdominal abscess after adjusting for confounders. RESULTS: Of 763 patients, 153 (20%) developed intra-abdominal abscesses. Eighty-one patients with intra-abdominal abscesses (53%) underwent percutaneous abscess drainage. Intra-abdominal abscess was independently associated with a nearly 8-fold increased risk of 30-day readmission (adjusted risk ratio, 7.8 [95% confidence interval, 4.7-13.0]). Patients who developed an intra-abdominal abscess required 6.1 excess hospital bed days compared to patients without intra-abdominal abscess (95% confidence interval, 5.3-7.0). Adjusted mean hospital costs for patients with intra-abdominal abscess totaled $27,394 (95% confidence interval, $25,688-$29,101) versus $15,586 (95% confidence interval, $15,102-$16,069) for patients without intra-abdominal abscess. Intra-abdominal abscess was associated with an incremental cost of $11,809 (95% confidence interval, $10,029-$13,588). Hospital room costs accounted for 66% of excess costs. CONCLUSION: Postoperative intra-abdominal abscess nearly doubled pediatric perforated appendicitis costs, primarily due to more hospital bed days and associated room costs. Intra-abdominal abscesses resulted in estimated excess costs of $1.8 million during the study period. Even small reductions in intra-abdominal abscess rates or hospital bed days could yield substantial health care savings.

Variability in opioid prescribing practices, knowledge, and beliefs: A survey of providers caring for pediatric surgical patients.

BACKGROUND/PURPOSE: Comprehensive opioid stewardship programs require collective stakeholder alignment and proficiency. We aimed to determine opioid-related prescribing practices, knowledge, and beliefs among providers who care for pediatric surgical patients. METHODS: A single-center, cross-sectional survey was conducted of attending physicians, residents, and advanced practice providers (APPs), who managed pediatric surgical patients. RESULTS: Of 110 providers surveyed, 75% completed the survey. Over half of respondents (n = 43, 52%) reported always/very often prescribing opioids at discharge, with residents reporting the highest rate (66%). Provider types had varying prescribing patterns, including what types of opioids and non-opioids they prescribed. There was a lack of formal training, particularly among residents, of which only 42% reported receiving formal opioid prescribing education. Finally, although only 28% of providers felt that the opioid epidemic affects children, 48% believed pediatric providers' prescribing patterns contributed to the opioid epidemic as a whole, and 80% reported changing their prescribing practices in response. CONCLUSIONS: Significant variability exists in opioid prescribing practices, knowledge, and beliefs among providers who care for pediatric surgical patients. Effective opioid stewardship requires comprehensive policies, pediatric specific guidelines, and education for all providers caring for children to align provider proficiency and optimize prescribing patterns.

Are we missing the near misses in the OR?-underreporting of safety incidents in pediatric surgery.

BACKGROUND: Electronic hospital variance reporting systems used to report near misses and adverse events are plagued by underreporting. The purpose of this study is to prospectively evaluate directly observed variances that occur in our pediatric operating room and to correlate these with the two established variance reporting systems in our hospital. MATERIALS AND METHODS: Trained individuals directly observed pediatric perioperative patient care for 6 wk to identify near misses and adverse events. These direct observations were compared to the established handwritten perioperative variance cards and the electronic hospital variance reporting system. All observations were analyzed and categorized into an additional six safety domains and five variance categories. The chi-square test was used, and P-values < 0.05 were considered statistically significant. RESULTS: Out of 830 surgical cases, 211 were audited by the safety observers. During this period, 137 (64%) near misses were identified by direct observation, while 57 (7%) handwritten and 8 (1%) electronic variance were reported. Only 1 of 137 observed events was reported in the handwritten variance system. Five directly observed adverse events were not reported in either of the two variance reporting systems. Safety observers were more likely to recognize time-out and equipment variances (P < 0.001). Both variance reporting systems and direct observation identified numerous policy and process issues. CONCLUSIONS: Despite multiple reporting systems, near misses and adverse events remain underreported. Identifying near misses may help address system and process issues before an adverse event occurs. Efforts need to be made to lessen barriers to reporting in order to improve patient safety.

The Impact of Socioeconomic Status on Appendiceal Perforation in Pediatric Appendicitis.

OBJECTIVE: To assess the impact of socioeconomic status (SES) on pediatric appendicitis outcomes using the validated Agency for Healthcare Research and Quality (AHRQ) SES Index and incorporating block-group data. STUDY DESIGN: We reviewed all patients <18 years old who underwent appendectomy for acute appendicitis from 2009-2013 at our institution. Patient addresses were geocoded and linked to 2010 US Census SES block-group data to determine composite AHRQ SES Index scores based on 7 publically reported SES variables. The primary outcome was appendiceal perforation, and the impact of SES scores, age, race, and insurance status on perforation rates were assessed through regression analyses. RESULTS: Of 1501 patients, 510 (34%) had perforated appendicitis. On bivariate analysis, components of the SES Index associated with an increased perforation rate included lower household income, lower percentage of adults with college education, and higher percentage of adults with <12th grade education (all P < .05). On multivariate analysis, age ≤ 10 years (OR 1.7, 95% CI 1.4-2.2) and public insurance (OR 1.5, 95% CI 1.2-2.0) were associated with increased odds of perforation. CONCLUSIONS: This study used the AHRQ SES scoring system to evaluate SES and its influence on appendiceal perforation. Among our cohort of pediatric patients, the risk of perforation was multifactorial, and younger age and public insurance were stronger predictors of perforation than SES.

The Congenital Diaphragmatic Hernia Study Group Registry.

Congenital diaphragmatic hernia (CDH) is a rare anomaly with an incidence between 1/2,500 and 1/3,000 live births. The rarity of the disease makes it difficult to design powerful studies leading to accurate and meaningful evidence. For rare diseases, the development of multicenter international registries may help in collecting data and give an overall picture of the disease. In this review, we will describe the development of the CDH study group, we will describe its work methodology, and the results obtained since its birth in 1995.

Impact of a 24-hour discharge pathway on outcomes of pediatric appendectomy.

BACKGROUND: Clinical pathways for simple (nonperforated, nongangrenous) appendicitis potentially could decrease hospital length of stay (LOS) through standardization of patient care. Our institution initiated a simple appendicitis pathway for children with the goal of less than 24-hour discharge (same-day discharge, SDD) and evaluated its effectiveness. METHODS: A prospective cohort of pediatric patients (<18 years of age) who underwent appendectomy for simple appendicitis after implementation of a SDD pathway were compared with a historic cohort of similar patients in this same large children's hospital. Primary outcomes included LOS, surgical-site infections, and readmissions. Mann Whitney U test, Fischer exact test, χ(2) test, and logistic regression were used. RESULTS: Between June 2009 and May 2013, 1,382 appendectomies were performed; 794 (57%) were for simple appendicitis (316 prepathway and 478 pathway). Hospital LOS decreased 37% after pathway implementation from a median (interquartile range) of 35 (20-50) hours to 22 (9-55) hours (P < .001). SDD increased from 13% to 58% (P < .001). Infectious complications were unchanged (1.6% vs 1.8%, P = .82), but readmissions increased (1.2% vs 4.2%, P = .02). CONCLUSION: A standardized pathway for simple appendicitis that targets SDD can be achieved in children; however, a slight increase in readmissions was noted. High risk for readmission, cost effectiveness, and generalizability need to be further determined.