Assessing Alternative Approaches for Wound Closure in a National Pediatric Learning Health System.

INTRODUCTION: Our objective was to perform a feasibility study using real-world data from a learning health system (LHS) to describe current practice patterns of wound closure and explore differences in outcomes associated with the use of tissue adhesives and other methods of wound closure in the pediatric surgical population to inform a potentially large study. METHODS: A multi-institutional cross-sectional study was performed of a random sample of patients <18 y-old who underwent laparoscopic appendectomy, open or laparoscopic inguinal hernia repair, umbilical hernia repair, or repair of traumatic laceration from January 1, 2019, to December 31, 2019. Sociodemographic and operative characteristics were obtained from 6 PEDSnet (a national pediatric LHS) children's hospitals and OneFlorida Clinical Research Consortium (a PCORnet collaboration across 14 academic health systems). Additional clinical data elements were collected via chart review. RESULTS: Of the 692 patients included, 182 (26.3%) had appendectomies, 155 (22.4%) inguinal hernia repairs, 163 (23.6%) umbilical hernia repairs, and 192 (27.8%) traumatic lacerations. Of the 500 surgical incisions, sutures with tissue adhesives were the most frequently used (n = 211, 42.2%), followed by sutures with adhesive strips (n = 176, 35.2%), and sutures only (n = 72, 14.4%). Most traumatic lacerations were repaired with sutures only (n = 127, 64.5%). The overall wound-related complication rate was 3.0% and resumption of normal activities was recommended at a median of 14 d (interquartile ranges 14-14). CONCLUSIONS: The LHS represents an efficient tool to identify cohorts of pediatric surgical patients to perform comparative effectiveness research using real-world data to support medical and surgical products/devices in children.

An integrated approach to surgery and primary care systems strengthening in low- and middle-income countries: building a platform to deliver across the spectrum of disease.

BACKGROUND: Surgical services in low- and middle income countries (LMICs) must be considered within the context of a coordinated strategy for building primary care systems. Weak front-line primary care systems lead to delayed presentation and poor follow-up of patients with surgical illness, increasing the risk of poor outcomes. METHODS: Here we propose a framework to integrating surgery and primary care, organized around basic primary care principles of access, longitudinal care, coordination, integration and equity. RESULTS: Making surgical care accessible will require frontline provider capacity to screen for and recognize common surgical conditions, as well as to deliver certain basic surgical services themselves. Making this care effective will require strengthening the capacity of interdisciplinary teams to provide longitudinal care, involving coordinated networks for referral, communication with and mentorship by more specialized providers, and postoperative follow-up. Innovative approaches to information and communication technology can help to overcome the transportation and infrastructure barriers that jeopardize both access and effectiveness. Explicit integration of surgical and primary care programs at the managerial and administrative levels, as well as at the point-of-care, will also be critical. Taking a pro-equity approach can ensure that populations with the greatest unmet needs are effectively reached. CONCLUSION: Utilizing the pillars of effective primary care as a guiding framework to design, implement, and scale surgical programs in LMICs offers an opportunity for strengthening and enhancing the quality of health systems as a whole.