Hospital and Professional Charges and Reimbursement Patterns in Pediatric Extracorporeal Membrane Oxygenation.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) is an expensive therapeutic modality. We sought to identify the main charge contributors to patient bills and analyze their patterns of reimbursement. We additionally sought to evaluate the impact of 2015 Current Procedural Terminology (CPT) code changes in professional billing for pediatric surgeons. METHODS: A retrospective review of ECMO cases at a standalone quaternary children's hospital between 2008-2017 was performed. Itemized hospital and professional bills were analyzed. RESULTS: Top charges included room rates, nitric oxide, medications, invasive support and monitoring, and laboratory testing. Average reimbursement was ∼60% for hospital and ∼36% for professional bills. CPT code changes in 2015 represented a 65% reduction in RVUs and 46% reduction in professional charges. Medicaid reimbursement for professional billing remained stable at 9%, and commercial reimbursement fell from 70% to 59% during the study period. CONCLUSIONS: The main drivers of ECMO charges are unrelated to ECMO supplies or surgery. Evidence-based guidelines for ECMO management could make a difference in healthcare expenditure. Modern CPT codes depreciate RVUs and professional charges, compromising revenue. As the infrastructure required to provide this service is costly, diminishing returns may limit access to this therapy.

The Severity of Pectus Excavatum Defect Is Associated With Impaired Cardiopulmonary Function.

BACKGROUND: Repair of pectus excavatum has cosmetic benefits, but the physiologic impact remains controversial. The aim of this study was to characterize the relationship between the degree of pectus excavatum and cardiopulmonary dysfunction seen on cardiac magnetic resonance (CMR) imaging, cardiopulmonary exercise testing (CPET), and pulmonary function testing (PFT). METHODS: A single-center analysis of CMR, CPET, and PFT was conducted. Regression models evaluated relationships between pectus indices and the clinical end points of cardiopulmonary function. RESULTS: Data from 345 CMRs, 261 CPETs, and 281 PFTs were analyzed. Patients were a mean age of 15.2 ± 4 years, and 81% were aged <18 years. The right ventricular ejection fraction (RVEF) was <0.50 in 16% of patients, left ventricular ejection fraction (LVEF) was <0.55 in 22%, RVEF Z-score was < -2 in 32%, and the LVEF Z-score was < -2 in 18%. CPET revealed 33% of patients had reduced aerobic fitness. PFT results were abnormal in 23.1% of patients. Adjusted analyses revealed the Haller index had significant (P < .05) inverse associations with RVEF and LVEF. CONCLUSIONS: The severity of pectus excavatum is associated with ventricular systolic dysfunction. Pectus excavatum impacts right and left ventricular systolic function and can also impact exercise tolerance. The Haller index and correction index may be the most useful predictors of impairment.

Can complex surgical interventions be standardized? Reaching international consensus on posterior sagittal anorectoplasty using a modified-Delphi method.

BACKGROUND/PURPOSE: In an effort to standardize educational experience, address future physician shortages, and improve quality of care to patients, many surgical specialties are discussing how to maximize exposure to index cases. One solution being explored is telementoring, which requires a well-developed educational curriculum with intraoperative objectives. The American College of Surgery Telementoring Task Force selected anorectal malformation and posterior sagittal anorectoplasty (PSARP) for the repair of imperforate anus as the initial educational focus for this pilot. The purpose of this study was to obtain international consensus on intraoperative learning objectives for a complex surgical procedure. METHODS: A multidisciplinary team of medical educators and pediatric surgery experts created an outline of essential curricular content and intraoperative learning objectives for PSARP in three clinical scenarios. Twelve international subject matter experts were identified meeting strict inclusion criteria. Intraoperative checklists were revised using the modified-Delphi process. RESULTS: After five rounds of modifications to the intraoperative checklists, international consensus was achieved for three different clinical scenarios requiring a PSARP: perineal or vestibular fistula, low prostatic fistula, and bladder neck fistula. CONCLUSIONS: A modified-Delphi approach was successful in generating guidelines for surgical techniques that can be used to standardize intraoperative teaching and expectations for trainees. TYPE OF STUDY: Diagnostic study LEVEL OF EVIDENCE: Level V (expert opinion).

Catching the red eye: A retrospective review of factors associated with retinal hemorrhage in child physical abuse.

BACKGROUND/PURPOSE: Accurate identification of child physical abuse is crucial during the evaluation of injured children. Retinal hemorrhages (RH) are used for diagnosis, but clear criteria for screening with direct fundoscopic exam are lacking. We sought to identify key factors associated with RH to guide evaluations. METHODS: Electronic medical records for patients <1 year of age presenting to a Level I Pediatric Trauma Center with unwitnessed head injury from January 2015 to December 2018 were retrospectively reviewed. Multivariable logistic regression was used to identify factors associated with RH. RESULTS: Two hundred and seventy-six patients were included; 63% underwent direct fundoscopic examination, of which 23% were positive and 77% were negative for RH. Unscreened patients tended to be older and have isolated skull fractures. Multivariable regression analysis revealed that abnormal GCS and subdural hemorrhage were positively associated with a diagnosis of retinal hemorrhage, while isolated skull fracture was negatively associated. CONCLUSIONS: Children under 1 year of age with subdural hemorrhage have a greater risk of associated RH and should undergo routine screening with direct fundoscopic examination. Conversely, those with isolated skull fractures may not require an ophthalmology consultation. Standardized screening protocols may help reduce the risk of missing child physical abuse. LEVEL OF EVIDENCE: III (Diagnostic Test).

Risk profile of subcutaneous port placement in small children.

BACKGROUND/PURPOSE: Long-term central venous access is a safe and common procedure in children. However, complications with devices are a reality. Smaller children are thought to have a higher rate of complication after port placement, and some surgeons avoid placing ports with an arbitrary weight cutoff out of concern for surgical site morbidity. METHODS: We performed a multi-institutional retrospective review of 500 patients less than 5 years of age undergoing port placement at three large volume children's hospitals from 2014 to 2018. Patients were divided by weight greater than or less than 10 kg at the time of insertion. Statistical analysis was performed to evaluate for differences in outcomes between the two groups. RESULTS: The majority of ports were placed for chemotherapy access (71.8%). Other indications included long-term infusions (18.8%) and difficult chronic IV access (9.4%). Of the 500 charts reviewed, 110 (22%) experienced some documented complication (28.9% <10 kg, 20.6% >10 kg, p = 0.096). There were no differences between the two groups in terms of the type or timing of complications. Overall, 16.3% of ports required removal prior to the end of therapy owing to a complication. Complication rate per day with the port in place was not different between the two groups (<10 kg: 0.68 complications/1000 port-days vs >10 kg 0.44 complications/1000 port-days, p = 0.068). CONCLUSION: Weight less than 10 kg was not associated with a significantly higher incidence of any type of port complication in our cohort. This suggests that concern for complications should not exclude children less than 10 kg from port placement. TYPE OF STUDY: Multi-institutional retrospective review. LEVEL OF EVIDENCE: Level III.

Recurrence after laparoscopic high ligation in adolescents: A multicenter international retrospective study of ten hospitals.

PURPOSE: Inguinal hernia repairs are among the most common operations performed by pediatric surgeons. Laparoscopic high ligation is a popular technique, but its recurrence rate in adolescents is unknown. We hypothesized that recurrence after laparoscopic high ligation in adolescents would be similar to open repair (1.8%-6.3%). METHODS: We evaluated adolescent patients (12-18 years old at the time of surgery) who underwent laparoscopic high ligation across eleven hospitals. At least six months postoperatively, they were contacted by telephone for follow-up. Variables analyzed included demographics, operative details, recurrence, and other complications. RESULTS: A total of 144 patients were enrolled. One hospital (n=9) had a recurrence rate of 44.4%, compared to 3.0% (4/135) for the other hospitals. By accounting for 50.0% of recurrences, it represented a statistical outlier and was excluded, leaving 135 patients for analysis. The median age was 14 years, and 63.7% were male. Recurrence with the excluded center was 5.6% (8/144). Use of absorbable suture (OR 42.67, CI 4.41-412.90, p<0.01) and braided suture (OR 12.10, CI 1.54-95.25, p=0.02) was weakly associated with recurrence. Recurrence was not significantly different from published results. CONCLUSION: Laparoscopic high ligation of adolescent inguinal hernias has a recurrence rate similar to open repair when performed by experienced surgeons. TYPE OF STUDY: Prognosis study (retrospective study) LEVEL OF EVIDENCE: Level II.

Journal of Pediatric Surgery: Effects of an automated social media strategy for knowledge dissemination.

BACKGROUND/PURPOSE: With increasing publications, it's hard to keep up with surgical literature. Social media is a valuable educational resource with global reach. We sought to analyze the impact of an automated social media strategy for the Journal of Pediatric Surgery (JPS). METHODS: Analytics for March-August 2019 were retrospectively reviewed for automated posts using a SocialPilot queue from the journal's RSS feed. Descriptive and inferential statistics were utilized to analyze performance, including journal article views. RESULTS: One hundred sixty-five posts amassed 512,316 impressions and 9,795 article views. Facebook had greater overall impact (p < 0.01). Twitter was stronger when adjusted by number of followers (p < 0.01). Engagements and article views had strong correlation between platforms (p < 0.01). Day of the week had limited impact. Photographs were the preferred content format (p < 0.05). Topic had the highest effect on performance (p < 0.05) - with colorectal, EA/TEF, and general pediatric surgery leading to higher reach and engagement. ECMO/CDH was the least popular. Comments and shares were negligible. CONCLUSIONS: We reached 3,105 users, with 59 article views per post. Topic had the strongest effect on performance. For comparison, custom infographics reached 7,368 users and averaged 101 article views. Alternative knowledge dissemination strategies are likely needed to foster online discussion and build more robust forums for collaboration. TYPE OF STUDY: Retrospective, Non-clinical Study. LEVEL OF EVIDENCE: Level III.

The chest wall gender divide: females have better cardiopulmonary function and exercise tolerance despite worse deformity in pectus excavatum.

PURPOSE: Pectus excavatum (PE) is a chest wall deformity of variable severity and symptomatology. Existing female-specific literature highlights breast asymmetry and cosmetic reconstruction. We sought to evaluate gender differences in cardiopulmonary function. METHODS: Cardiac MRIs, pulmonary function tests (PFTs), and cardiopulmonary exercise tests (CPETs) were reviewed in 345 patients undergoing preoperative evaluation for PE. Regression modeling was used to evaluate associations between gender and clinical endpoints of cardiopulmonary function. RESULTS: Mean age was 15.2 years, 19% were female, 98% were white. Pectus indices included median Haller Index (HI) of 4.8, mean depression index (DI) of 0.63, correction index (CI) of 33.6%, and Cardiac Compression Index (CCI) of 2.79. Cardiac assessment revealed decreased right and left ventricular ejection fraction (RVEF, LVEF) in 16% and 22% of patients, respectively. PFTs and CPETs were abnormal in ~ 30% of patients. While females had deeper PE deformities-represented by higher pectus indices-they had superior function with higher RVEF, LVEF Z-scores, FEV1, VO2 max, O2 pulse, work, and breathing reserve (p < 0.05). CONCLUSION: Despite worse PE deformity and symptomatology, females had a better cardiopulmonary function and exercise tolerance than males. Further research is needed to assess the precise mechanisms of this phenomenon and postoperative outcomes in this population.

Avoiding unnecessary bronchoscopy in children with suspected foreign body aspiration using computed tomography.

BACKGROUND: Bronchoscopy is the standard of care for diagnosis and treatment of foreign body aspiration (FBA). Drawbacks of this approach include its invasiveness, the potential for exacerbation of reactive airway disease, and the need for general anesthesia. Computed tomography (CT) can potentially identify patients with FBA, thereby avoiding unnecessary bronchoscopies in patients with at-risk reactive airways. METHODS: A retrospective review was performed to identify patients who underwent CT and/or bronchoscopy for suspected foreign body aspiration (FBA) from June 2012 to September 2018. Variables included clinical history, exam findings, radiographic findings, and operative findings. A telephone survey was performed for patients who had a CT without bronchoscopy. Three radiologists performed rereads of all CTs. RESULTS: A total of 133 patients were evaluated for FBA, and 84 were treated with bronchoscopy. For those with a CT demonstrating a foreign body, findings were confirmed on bronchoscopy in 17/18 (94.4%). For those with bronchoscopy alone, 39/64 (60.9%) were found to have a foreign body (p < 0.01). CT excluded FBA in 49 patients. Sensitivity was 100%, specificity was 98%, and interobserver reliability was excellent (κ = 0.88). CONCLUSION: CT is an accurate and reliable diagnostic tool in the evaluation of FBA that can increase the rate of positive bronchoscopy. TYPE OF STUDY: Retrospective comparative study. LEVEL OF EVIDENCE: Level III.

Digital transformation of academic medicine: Breaking barriers, borders, and boredom.

Academic medicine is experiencing an exponential increase in knowledge, evidenced by approximately 2.5 million new articles published each year. As a result, staying apprised of practice-changing findings as a busy clinician is nearly impossible. The traditional methods of staying up to date through reading textbooks and journal articles or attending an annual conference are no longer enough. These old approaches do not distribute knowledge equally around the world or inform practitioners adequately of what they need to provide the best patient care. Luckily, digital technology, which contributed to our ability to generate this explosion in research, also holds the solution. We believe the improved filtration and curation of new knowledge will come through the combination of three elements: machine learning, crowd-sourcing, and new digital platforms. Machine learning can be harnessed to identify high-quality research while avoiding unconscious bias towards authors, institutions, or positions, and to create personalized reading lists that encompass essential articles while also addressing personal knowledge gaps. The crowd can also serve to curate the best research through an open-source platform that exposes each step of the research process, from developing questions through discussion of findings, functionally replacing editorial boards with crowd peer-review. Finally, embracing new digital platforms and multimedia delivery formats will move academic medicine into the 21st century, broadening its reach to diverse, international, and multigenerational learners. The digital age will continue to change life as we know it, but we have the power - and the responsibility - to control how it transforms academic medicine. LEVEL OF EVIDENCE: V (Expert).

It Is a Wrap! Or Is It?: The Role of Fundoplication in Infant Feeding Intolerance.

Purpose: Fundoplication is one of the most common procedures performed by pediatric surgeons, frequently for gastroesophageal reflux with feeding intolerance. No consensus exists in its management, with multiple institutions opting for medical therapy over surgical intervention. Methods: A case-based survey was administered at a national pediatric surgery conference. Clinical vignettes described former-premature infants with reflux and feeding intolerance with or without failure to thrive (FTT), neurological impairment, complex cardiopathy, and respiratory symptoms. Odds ratios (ORs) for fundoplication were calculated from participants' responses. Results: Surgeons elected to perform fundoplication in 14%-74% of cases. The OR for performing fundoplication in the presence of FTT was 1.84 (confidence interval [CI] 1.34-2.54, P = .0002) overall, achieving significance in subgroup analysis for cardiopathy (OR 3.56, CI 1.88-6.71, P = .0001) and neurological impairment (OR 1.79, CI 1.04-3.07, P = .04), but not in the absence of these comorbidities (OR 1.05, CI 0.61-1.83, P = .86). The OR for fundoplication in the presence of neurological impairment was 1.97 (CI 1.34-2.90, P = .0005) and that for cardiopathy was 1.70 (CI 1.20-2.40, P = .003), independent of FTT status. In subgroup analysis, the greatest predictors for fundoplication were neurological impairment with FTT (OR 2.63, CI 1.55-4.48, P = .0004) and complex cardiopathy with FTT and cough/syncope (OR 7.14, CI 4.05-12.58, P < .0001). Presence of cardiopathy without FTT had the overall lowest odds of fundoplication (OR 0.40, CI 0.21-0.78, P = .006). Conclusion: Surgeons tend to perform fundoplication in the presence of FTT and other comorbidities, particularly when these are concurrent. Respiratory symptoms are a strong predictor for fundoplication in patients with complex cardiopathies.

Distention of the Immature Left Ventricle Triggers Development of Endocardial Fibroelastosis: An Animal Model of Endocardial Fibroelastosis Introducing Morphopathological Features of Evolving Fetal Hypoplastic Left Heart Syndrome.

BACKGROUND: Endocardial fibroelastosis (EFE), characterized by a diffuse endocardial thickening through collagen and elastin fibers, develops in the human fetal heart restricting growth of the left ventricle (LV). Recent advances in fetal imaging indicate that EFE development is directly associated with a distended, poorly contractile LV in evolving hypoplastic left heart syndrome (HLHS). In this study, we developed an animal model of EFE by introducing this human fetal LV morphopathology to an immature rat heart. METHODS AND RESULTS: A neonatal donor heart, in which aortic regurgitation (AR) was created, was heterotopically transplanted into a recipient adult rat. AR successfully induced the LV morphology of evolving HLHS in the transplanted donor hearts, which resulted in the development of significant EFE covering the entire LV cavity within two weeks postoperatively. In contrast, posttransplants with a competent aortic valve displayed unloaded LVs with a trace of EFE. CONCLUSIONS: We could show that distention of the immature LV in combination with stagnant flow triggers EFE development in this animal model. This model would serve as a robust tool to develop therapeutic strategies to treat EFE while providing insight into its pathogenesis.