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BACKGROUND: In 2004, our level 1 regional pediatric trauma center created a protocol to activate ECMO for children with suspected hypothermic cardiac arrest based on inclusion criteria: serum potassium ≤9, submersion <90 min, and core body temperature <30 °C. In 2017, Pasquier et al. developed a model to help predict the survival of adults after hypothermic cardiac arrest (HOPE score) that has not been validated in children. We sought to apply this score to our pediatric patient population to determine if it can optimize our patient selection. METHODS: This was a retrospective review of all patients cannulated onto VA ECMO for hypothermic cardiac arrest between 2004 and 2022. We used abstracted data points to calculate the HOPE score for our patient population, both with and without presumed asphyxia. RESULTS: Over 19 years, 18 patients were cannulated for suspected hypothermic arrest, with three survivors (17 %). The HOPE score survival prediction ranged from 1 to 86 % with presumed asphyxia and 6-98 % without presumed asphyxia. Survivor HOPE scores ranged from 9 to 86 % with presumed asphyxia and 42-98 % without presumed asphyxia. Non-survivors' scores ranged 1-29 % with asphyxia and 6-57 % without asphyxia. A cutoff of >5 % predicted survival with asphyxia for ECMO could have decreased our cannulations by half without missing survivors. CONCLUSION: ECMO can be a lifesaving measure for specific children after hypothermic arrest. However, identifying the patients that will benefit from this resource-intensive intervention remains difficult. HOPE score utilization may decrease the rate of futile cannulation in children, but multi-centered research is needed in the pediatric population.
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PURPOSE: The utilization of home antibiotic therapy following surgery for complicated pediatric appendicitis is highly variable. In 2019, we stopped home antibiotic therapy in this cohort at our institution. We sought to evaluate our outcomes following this protocol change. METHODS: We queried our institutional NSQIP Pediatrics data for all children undergoing appendectomy for complicated appendicitis between January 2015 and May 2022. We identified two cohorts: those discharged with home antibiotics (1/1/15-4/30/19) and those discharged with no home antibiotics (5/1/19-4/30/22). Both groups were treated with response based parenteral antibiotics while hospitalized and discharged when clinically well. Our primary outcome was postoperative deep organ space infection requiring intervention (drainage, aspiration, reoperation, or antibiotics). Secondary outcomes included length of stay, superficial site infection, Clostridium difficile colitis, ER visits, post-operative CT imaging, and readmission. RESULTS: There were 185 patients in the home antibiotic group (83% discharged with antibiotics) and 121 patients in the no home antibiotic group (8.3% discharged with antibiotics). There were no significant differences in deep organ space infection requiring intervention (7% vs. 7.4%, p = 1.0). Our length of stay was not different (4.5 days vs. 3.95 days, p = 0.32), nor were other secondary outcomes or patient characteristics. All patients had documented follow-up. CONCLUSIONS: We did not identify differences in deep organ space infections, length of stay or other events after eliminating home antibiotic therapy in our complicated appendicitis cohort. The use of home antibiotics following surgery for complicated appendicitis should be reconsidered. LEVEL OF EVIDENCE: III.
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Antibacterianos , Apendicite , Humanos , Criança , Antibacterianos/uso terapêutico , Apendicite/complicações , Apendicite/tratamento farmacológico , Apendicite/cirurgia , Alta do Paciente , Resultado do Tratamento , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/tratamento farmacológico , Apendicectomia , Estudos Retrospectivos , Tempo de InternaçãoRESUMO
BACKGROUND: Operating rooms generate significant greenhouse gas emissions. Our objective was to assess current institutional climate-smart actions and pediatric surgeon perceptions regarding environmental stewardship efforts in the operating room. METHODS: A survey was distributed to members of the American Pediatric Surgical Association in June 2022. The survey was piloted among ten general surgery residents and two professional society cohorts of pediatric surgeons. Comparisons were made by demographic and practice characteristics. RESULTS: Survey response rate was 15.9% (n = 160/1009) and included surgeons predominantly from urban (n = 93/122, 76.2%) and academic (n = 84/122, 68.9%) institutions. Only 9.8% (n = 12/122) of pediatric surgeons were currently involved in operating room environmental initiatives. The most common climate-smart actions were reusable materials and equipment (n = 120/159, 75.5%) and reprocessing of medical devices (n = 111/160, 69.4%). Most surgeons either strongly agreed (n = 48/121, 39.7%) or agreed (n = 62/121, 51.2%) that incorporation of environmental stewardship practices at work was important. Surgeons identified reusable materials/equipment (extremely important: n = 61/129, 47.3%, important: n = 38/129, 29.5%) and recycling (extremely important: n = 68/129, 52.7%, important: n = 29/129, 22.5%) as the most important climate-smart actions. Commonly perceived barriers were financial (extremely likely: n = 47/123, 38.2%, likely: n = 50/123, 40.7%) and staff resistance to change (extremely likely: n = 29/123, 23.6%, likely: n = 60/123, 48.8%). Regional differences included low adoption of energy efficiency strategies among respondents from southern states (n = 0/26, p = 0.01) despite high perceived importance relative to other regions (median: 5, IQR: 4-5 vs median: 4, IQR 4-5, p = 0.04). CONCLUSIONS: While most pediatric surgeons agreed that environmental stewardship was important, less than 10% are currently involved in initiatives at their institutions. Opportunities exist for surgical leadership surrounding implementation of climate-smart actions. LEVEL OF EVIDENCE: Level III.
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Salas Cirúrgicas , Cirurgiões , Criança , Humanos , Estados Unidos , Inquéritos e QuestionáriosRESUMO
The use of computed tomography (CT) in the emergency department (ED) evaluation of pediatric patients for suspected appendicitis can be safely reduced. However, published examples of reduced CT use also report increased MRI utilization, ED length of stay, hospitalization rates, and in-ED surgical consultation. In addition, previous studies recommended follow-up for undifferentiated abdominal pain, yet none with pediatric surgeons. Therefore, we implemented a diagnostic algorithm that includes an option for next-day surgery clinic follow-up in cases where uncertainty remains after appendix ultrasound (US) to reduce CT utilization without increasing hospital-based resources. Methods: We implemented a diagnostic algorithm in January 2014. We retrospectively identified 4,577 patients who underwent an evaluation for suspected appendicitis from January 2012 to September 2015. CT utilization was compared before and after implementation using Statistical Process Control. In addition, we evaluated secondary outcomes, including US utilization, hospital admission, surgery clinic follow-up, ED surgery consultation, ED return visits within 7 days, and ED length of stay. Results: Following the implementation of the algorithm, CT utilization decreased significantly from 13.8% to 6%. Forty-eight patients were evaluated the next day in the optional pediatric surgery clinic for 21 months after implementation. There was no significant change in US utilization, hospital admission, ED surgery consultation, ED return visits within 7 days, or ED length of stay. Conclusion: We achieved decreased CT utilization without an increase in the utilization of other hospital-based resources after implementing a pediatric appendicitis evaluation algorithm that includes the option for next-day pediatric surgery clinic follow-up.
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BACKGROUND: The Coronavirus Disease 2019 pandemic provided a natural experiment to study the effect of social distancing on the risk of developing Hirschsprung's Associated Enterocolitis (HAEC). METHODS: Using the Pediatric Health Information System (PHIS), a retrospective cohort study of children (<18 years) with Hirschsprung's Disease (HSCR) across 47 United States children's hospitals was performed. The primary outcome was HAEC admissions per 10,000 patient-days. The exposure (COVID-19) was defined as April 2020-December 2021. The unexposed (historical control) period was April 2018-December 2019. Secondary outcomes included sepsis, bowel perforation, intensive care unit (ICU) admission, mortality, and length of stay. RESULTS: Overall, we included 5707 patients with HSCR during the study period. There were 984 and 834 HAEC admissions during the pre-pandemic and pandemic periods, respectively (2.6 vs. 1.9 HAEC admissions per 10,000 patient-days, incident rate ratio [95% confidence interval]: 0.74 [0.67, 0.81], p < 0.001). Compared to pre-pandemic, those with HAEC during the pandemic were younger (median [IQR]: 566 [162, 1430] days pandemic vs. 746 [259, 1609] days pre-pandemic, p < 0.001) and more likely to live in the lowest quartile of median household income zip codes (24% pandemic vs. 19% pre-pandemic, p = 0.02). There were no significant differences in rates of sepsis (6.1% pandemic vs. 6.1% pre-pandemic, p > 0.9), bowel perforation (1.3% pandemic vs. 1.2% pre-pandemic, p = 0.8), ICU admissions (9.6% pandemic vs. 12% pre-pandemic, p = 0.2), mortality (0.5% pandemic vs. 0.6% pre-pandemic, p = 0.8), or length of stay (median [interquartile range]: 4 [(Pastor et al., 2009; Gosain and Brinkman, 2015) 2,112,11 days pandemic vs. 5 [(Pastor et al., 2009; Tang et al., 2020) 2,102,10 days pre-pandemic, p = 0.4). CONCLUSIONS: The COVID-19 pandemic was associated with significantly decreased incidence of HAEC admissions across US children's hospitals. Possible etiologies such as social distancing should be explored. LEVEL OF EVIDENCE: II.
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COVID-19 , Enterocolite , Doença de Hirschsprung , Perfuração Intestinal , Humanos , Criança , Incidência , Estudos Retrospectivos , Perfuração Intestinal/epidemiologia , Pandemias , COVID-19/epidemiologia , Enterocolite/epidemiologia , Enterocolite/etiologia , Doença de Hirschsprung/complicações , Hospitais PediátricosRESUMO
INTRODUCTION: This study evaluated North American pediatric surgeons' opinions and knowledge of business and economics in medicine and their perceptions of trends in their healthcare delivery environment. METHODS: We conducted an elective online survey of 1119 American Pediatric Surgical Association members. Over 8 mo, we iteratively developed the survey focused on four areas: opinion, knowledge, current practice environment, and trends in practice environment over the past 5 y. RESULTS: We received 227 (20.3%) complete surveys from pediatric surgeons. One hundred ninety four (85.5%) perceive healthcare as a business and most (85.9%) believe healthcare decisions may affect patients' out-of-pocket expenses. More than half (51.1%) of surgeons believe it has become more challenging to perform emergent cases and most believe staff quality has decreased for elective (56.4%) and emergent (63.0%) cases over the past 5 y. CONCLUSIONS: Pediatric surgeons recognize that medicine is a business and have concerns regarding the decreasing quality of operating room staff and the increasing difficulty providing surgical care over the last 5 y.
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Especialidades Cirúrgicas , Cirurgiões , Criança , Humanos , Estados Unidos , Inquéritos e Questionários , Gastos em Saúde , ComércioRESUMO
BACKGROUND: Nonoperative management of acute appendicitis is a safe and effective alternative to appendectomy, though rates of treatment failure and disease recurrence are significant. The purpose of this study was to determine whether COVID-19-positive children with acute appendicitis were more likely to undergo nonoperative management when compared to COVID-19-negative peers and to compare clinical outcomes and healthcare use for these groups. METHODS: A retrospective cohort study of children <18 years with acute appendicitis across 45 US Children's Hospitals during the first 12 months of the COVID-19 pandemic was performed. Operative management was defined as appendectomy or percutaneous drain placement, whereas nonoperative management was defined as admission with antibiotics alone. Multivariable hierarchical logistic regression using an exact matched cohort was used to determine the association between COVID-19 positivity and nonoperative management. The secondary outcomes included intensive care unit admission, mechanical ventilation, length of stay, nonoperative management failure rates, and hospital variation in nonoperative management. RESULTS: Of 17,481 children in the cohort, 581 (3.3%) were positive for COVID-19. The odds of nonoperative management was significantly higher in the COVID-19-positive group (adjusted odds ratio [95% confidence interval]: 13.4 [10.7-16.8], P < .001). Patients positive for COVID-19 had increased odds of intensive care unit admission (adjusted odds ratio [95% confidence interval]: 3.78 [2.01-7.12], P < .001) and longer length of stay (median 2 days vs 1 day, P < .001). Hospital rates of nonoperative management ranged from 0% to 100% for COVID-19-positive patients and 0% to 42% for COVID-19-negative patients. CONCLUSION: Children with concurrent acute appendicitis and COVID-19 positivity are significantly more likely to undergo nonoperative management. Both groups experience infrequent nonoperative management failure rates and rare intensive care unit admissions. Marked hospital variability in nonoperative management practices was demonstrated.
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Apendicite , COVID-19 , Humanos , Criança , Estados Unidos , Apendicite/cirurgia , Resultado do Tratamento , Estudos Retrospectivos , Pandemias , COVID-19/complicações , Antibacterianos/uso terapêutico , Apendicectomia , Doença Aguda , Hospitais , Tempo de InternaçãoRESUMO
INTRODUCTION: Significant racial and ethnic disparities exist for children presenting with acute appendicitis; however, it is unknown if disparities persist after initial management and hospital discharge. MATERIALS AND METHODS: We performed a retrospective cohort study of children (aged < 18 y) who underwent treatment for acute appendicitis in 47 U.S. Children's Hospitals between 2017 and 2019. Primary outcomes were 30-d emergency department (ED) visits and 30-d inpatient readmission. Hierarchical multivariable logistic regression models were developed to determine the association of race and ethnicity on the primary outcomes. Inverse odds-weighted mediation analyses were used to estimate the degree to which complicated disease, insurance status, urbanicity, and residential socioeconomic status- mediated disparate outcomes. RESULTS: A total of 67,303 patients were included. Compared with Non-Hispanic White children, Non-Hispanic Black (NHB) (odds ratio [OR] 1.40, 95% confidence interval [CI] 1.23-1.59) and Hispanic/Latinx (HL) children (OR 1.55, 95% CI 1.44-1.67) had higher odds of ED visits. Only NHB children had higher odds of readmission (OR 1.43, 95% CI 1.30-1.57). On a multivariable analysis, NHB (adjusted OR 1.19, 95% CI 1.04-1.36) and HL (adjusted OR 1.19, 95% CI 1.09-1.31) children had higher odds of ED visits. Insurance, disease severity, socioeconomic status, and urbanicity mediated 61.6% (95% CI 29.7-100%) and 66.3% (95% CI 46.9-89.3%) of disparities for NHB and HL children, respectively. CONCLUSIONS: Children of racial and ethnic minorities are more likely to visit the ED after treatment for acute appendicitis, but HL patients did not have a corresponding increase in readmission. These differences were mediated mainly by insurance status and urban residence. A lack of appropriate postdischarge education and follow-up may drive disparities in healthcare utilization after pediatric appendicitis.
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Apendicite , Etnicidade , Criança , Humanos , Apendicite/cirurgia , Análise de Mediação , Disparidades em Assistência à Saúde , Estudos Retrospectivos , Alta do Paciente , Assistência ao ConvalescenteRESUMO
BACKGROUND: With the widespread adoption of electronic healthcare records (EHRs) by US hospitals, there is an opportunity to leverage this data for the development of predictive algorithms to improve clinical care. A key barrier in model development and implementation includes the external validation of model discrimination, which is rare and often results in worse performance. One reason why machine learning models are not externally generalizable is data heterogeneity. A potential solution to address the substantial data heterogeneity between health care systems is to use standard vocabularies to map EHR data elements. The advantage of these vocabularies is a hierarchical relationship between elements, which allows the aggregation of specific clinical features to more general grouped concepts. OBJECTIVE: This study aimed to evaluate grouping EHR data using standard vocabularies to improve the transferability of machine learning models for the detection of postoperative health care-associated infections across institutions with different EHR systems. METHODS: Patients who underwent surgery from the University of Utah Health and Intermountain Healthcare from July 2014 to August 2017 with complete follow-up data were included. The primary outcome was a health care-associated infection within 30 days of the procedure. EHR data from 0-30 days after the operation were mapped to standard vocabularies and grouped using the hierarchical relationships of the vocabularies. Model performance was measured using the area under the receiver operating characteristic curve (AUC) and F1-score in internal and external validations. To evaluate model transferability, a difference-in-difference metric was defined as the difference in performance drop between internal and external validations for the baseline and grouped models. RESULTS: A total of 5775 patients from the University of Utah and 15,434 patients from Intermountain Healthcare were included. The prevalence of selected outcomes was from 4.9% (761/15,434) to 5% (291/5775) for surgical site infections, from 0.8% (44/5775) to 1.1% (171/15,434) for pneumonia, from 2.6% (400/15,434) to 3% (175/5775) for sepsis, and from 0.8% (125/15,434) to 0.9% (50/5775) for urinary tract infections. In all outcomes, the grouping of data using standard vocabularies resulted in a reduced drop in AUC and F1-score in external validation compared to baseline features (all P<.001, except urinary tract infection AUC: P=.002). The difference-in-difference metrics ranged from 0.005 to 0.248 for AUC and from 0.075 to 0.216 for F1-score. CONCLUSIONS: We demonstrated that grouping machine learning model features based on standard vocabularies improved model transferability between data sets across 2 institutions. Improving model transferability using standard vocabularies has the potential to improve the generalization of clinical prediction models across the health care system.
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BACKGROUND: The objective of this study was to develop a portal natural language processing approach to aid in the identification of postoperative venous thromboembolism events from free-text clinical notes. METHODS: We abstracted clinical notes from 25,494 operative events from 2 independent health care systems. A venous thromboembolism detected as part of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) was used as the reference standard. A natural language processing engine, easy clinical information extractor-pulmonary embolism/deep vein thrombosis (EasyCIE-PEDVT), was trained to detect pulmonary embolism and deep vein thrombosis from clinical notes. International Classification of Diseases (ICD) discharge diagnosis codes for venous thromboembolism were used as baseline comparators. The classification performance of EasyCIE-PEDVT was compared with International Classification of Diseases codes using sensitivity, specificity, area under the receiver operating characteristic curve, using an internal and external validation cohort. RESULTS: To detect pulmonary embolism, EasyCIE-PEDVT had a sensitivity of 0.714 and 0.815 in internal and external validation, respectively. To detect deep vein thrombosis, EasyCIE-PEDVT had a sensitivity of 0.846 and 0.849 in internal and external validation, respectively. EasyCIE-PEDVT had significantly higher discrimination for deep vein thrombosis compared with International Classification of Diseases codes in internal validation (area under the receiver operating characteristic curve: 0.920 vs 0.761; P < .001) and external validation (area under the receiver operating characteristic curve: 0.921 vs 0.794; P < .001). There was no significant difference in the discrimination for pulmonary embolism between EasyCIE-PEDVT and ICD codes. CONCLUSION: Accurate surveillance of postoperative venous thromboembolism may be achieved using natural language processing on clinical notes in 2 independent health care systems. These findings suggest natural language processing may augment manual chart abstraction for large registries such as NSQIP.
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Processamento de Linguagem Natural , Complicações Pós-Operatórias/diagnóstico , Melhoria de Qualidade , Trombose Venosa/diagnóstico , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Curva ROC , Estudos RetrospectivosRESUMO
OBJECTIVES: We present the development and validation of a portable NLP approach for automated surveillance of SSIs. SUMMARY OF BACKGROUND DATA: The surveillance of SSIs is labor-intensive limiting the generalizability and scalability of surgical quality surveillance programs. METHODS: We abstracted patient clinical text notes after surgical procedures from 2 independent healthcare systems using different electronic healthcare records. An SSI detected as part of the American College of Surgeons' National Surgical Quality Improvement Program was used as the reference standard. We developed a rules-based NLP system (Easy Clinical Information Extractor [CIE]-SSI) for operative event-level detection of SSIs using an training cohort (4574 operative events) from 1 healthcare system and then conducted internal validation on a blind cohort from the same healthcare system (1850 operative events) and external validation on a blind cohort from the second healthcare system (15,360 operative events). EasyCIE-SSI performance was measured using sensitivity, specificity, and area under the receiver-operating-curve (AUC). RESULTS: The prevalence of SSI was 4% and 5% in the internal and external validation corpora. In internal validation, EasyCIE-SSI had a sensitivity, specificity, AUC of 94%, 88%, 0.912 for the detection of SSI, respectively. In external validation, EasyCIE-SSI had sensitivity, specificity, AUC of 79%, 92%, 0.852 for the detection of SSI, respectively. The sensitivity of EasyCIE-SSI decreased in clean, skin/subcutaneous, and outpatient procedures in the external validation compared to internal validation. CONCLUSION: Automated surveillance of SSIs can be achieved using NLP of clinical notes with high sensitivity and specificity.
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Aplicativos Móveis , Processamento de Linguagem Natural , Infecção da Ferida Cirúrgica/diagnóstico , Adulto , Idoso , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Vigilância da População/métodos , Melhoria de Qualidade , Procedimentos Cirúrgicos Operatórios/normasRESUMO
BACKGROUND: The effect of the consolidation of neonatal pediatric surgical cases to limited surgeons within a hospital is unknown. We elected to model the distribution of complex neonatal procedures using an economic measure of market concentration, the Herfindahl-Hirschmann Index (HHI), and study its effect on outcomes of index pediatric surgical operations. METHODS: We used data from 49 US children's hospitals between 2007 and 2017 for the following procedures: congenital diaphragmatic hernia repair (CDH), esophageal atresia and tracheoesophageal fistula repair (EA/TEF), and pull-through for Hirschsprung disease (HD). Mixed effects logistic regression modeling was used to adjust for salient patient characteristics to determine the effect of HHI on in-hospital mortality, condition-specific one-year re-operation, and one-year unplanned readmissions. RESULTS: A total of 2270 infants were identified who underwent surgery for the three conditions of interest. On multivariable analysis, increasing HHI was not associated with differences in mortality or condition-specific re-operation within the first year. A decrease in the number of unplanned readmissions at highly concentrated centers was seen for HD (RR 0.8 CI (0.69-0.97), pâ¯=â¯0.02) and CDH (RR 0.4 CI (0.28-0.71), pâ¯<â¯0.001). CONCLUSIONS: Pediatric surgical specialization did not affect mortality or condition-specific re-operation. However, it did decrease the number of unplanned readmissions following CDH repairs and pull-throughs for HD. STUDY DESIGN: Retrospective Cohort Study. LEVEL OF EVIDENCE: Level II.
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Atresia Esofágica/cirurgia , Hérnias Diafragmáticas Congênitas/cirurgia , Doença de Hirschsprung/cirurgia , Especialidades Cirúrgicas/estatística & dados numéricos , Cirurgiões/estatística & dados numéricos , Fístula Traqueoesofágica/cirurgia , Feminino , Herniorrafia , Mortalidade Hospitalar , Hospitais , Humanos , Lactente , Recém-Nascido , Masculino , Complicações Pós-Operatórias , Período Pós-Operatório , Reoperação , Estudos RetrospectivosRESUMO
Previous studies have reported on the evaluation of patients diagnosed with appendicitis. Very little is known about all patients evaluated for suspected appendicitis. Patients evaluated beyond physical examination with laboratory and imaging testing, then found not to have appendicitis, are more difficult to identify. Data readily available in administrative databases may be used to identify these patients. METHODS: A multidisciplinary team developed a surrogate definition for evaluating suspected appendicitis in children based on available administrative data. Appendicitis was "suspected" if the patient underwent ultrasonography of the appendix or had a chief complaint of abdominal pain with both complete blood count performed and the word "appendicitis" in the ED provider note. Performance characteristics described the surrogate definition's ability to retrospectively identify patients evaluated for suspected appendicitis through comparison to a population identified via chart review. RESULTS: Compared with manual chart review of 498 patients from June 2014, the surrogate definition identified patients evaluated beyond physical examination for suspected appendicitis with a sensitivity of 79.8%, a specificity of 96.3%, a positive predictive value of 83.3%, and a negative predictive value of 95.3%. Of the 94 patients evaluated beyond physical examination for suspected appendicitis, 37 (39%) underwent appendectomy. CONCLUSIONS: Health systems can retrospectively identify children evaluated beyond physical examination for appendicitis using discrete administrative data and a word search of clinical notes. This surrogate definition for evaluation of suspected appendicitis enables research in quality improvement efforts and health care resource utilization.
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BACKGROUND: The incidence of and risk factors for Hirschsprung's-associated enterocolitis (HAEC) following pull-through have been limited to single institutions studies. We characterized the incidence of, risk factors for, and consequences of post-operative HAEC. METHODS: We identified children with Hirschsprung's Disease (HD) at US Children's Hospitals from 2007 to 2017 with and an associated pull-through operation at less than 1 year of age. HAEC readmissions were identified using ICD9/10 Diagnosis Codes and antibiotic administration. Hierarchical logistic regression models were developed for the risk factors for HAEC after pull-through and effects of recurrent HAEC on HD-related reoperations. RESULTS: We identified 2030 children with HD, and 138 (7%) who had two or more readmissions related to HAEC. The frequency of recurrent HAEC by hospital ranged from 0 to 33%. Pre-operative HAEC, history of central nervous system infection, and congenital neurologic anomalies were associated with increased risk of recurrent HAEC. Recurrent HAEC was associated with HD-specific re-operation (OR 5.2, CI 3.3-8.1, pâ¯<â¯0.001); however, it was not associated with risk of in-hospital mortality (OR 3.3, CI 0.88-12.1, pâ¯=â¯0.08). CONCLUSIONS: HAEC following pull-through occurs in a large proportion of infants with HD and predicts reoperation. Multicenter studies are needed to develop prediction models and treatment protocols for HAEC. LEVEL OF EVIDENCE: II TYPE OF STUDY: Retrospective cohort study.
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Enterocolite , Doença de Hirschsprung , Complicações Pós-Operatórias/epidemiologia , Enterocolite/epidemiologia , Enterocolite/etiologia , Doença de Hirschsprung/complicações , Doença de Hirschsprung/epidemiologia , Doença de Hirschsprung/cirurgia , Hospitais Pediátricos , Humanos , Incidência , Lactente , Estudos Retrospectivos , Fatores de RiscoRESUMO
OBJECTIVES: The objective of this study was to evaluate surgeon-prescribing patterns and opioid use for patients undergoing common otolaryngology surgeries. We hypothesized that there was little consistency across surgeons in prescribing patterns and that surgeons prescribed significantly more opioids than consumed by patients. METHODS: E-mail-based surveys were sent to all postoperative patients across a 23-hospital system. The survey assessed quantity of opioids consumed postoperatively, patient-reported pain control, and methods of opioid disposal. We compared patient-reported opioid consumption to opioids prescribed based on data in the electronic data warehouse. RESULTS: There was wide variation in prescribing between providers both in the quantity and type of opioids prescribed. Patients used significantly less opioids than they were prescribed (10 vs. 30 tablets, P < 0.001) for both opioid-exposed and opioid-naïve patients. More than 75% of patients had excess opioids remaining. CONCLUSION: Opioids are consistently overprescribed following ambulatory head and neck surgery. Otolaryngologists have an important role in the setting of the national opioid epidemic and should be involved in efforts to reduce excess opioids in their community. LEVEL OF EVIDENCE: 4 Laryngoscope, 130: 1913-1921, 2020.
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Procedimentos Cirúrgicos Ambulatórios , Analgésicos Opioides/uso terapêutico , Procedimentos Cirúrgicos Otorrinolaringológicos , Dor Pós-Operatória/prevenção & controle , Padrões de Prática Médica/estatística & dados numéricos , Feminino , Humanos , Masculino , Inquéritos e QuestionáriosRESUMO
BACKGROUND: There is increasing need to avoid excess opioid prescribing after surgery. We prospectively assessed overprescription in our hospital system and used these data to design a quality improvement intervention to reduce overprescription. MATERIALS AND METHODS: Beginning in January 2017, an e-mail-based survey to assess the quantity of opioids used postoperatively as well as patient-reported pain control was sent to all surgical patients in a 23-hospital system. In January 2018, as a quality improvement initiative, guidelines were given to surgeons based on patient consumption data. Prescription and consumption were then tracked prospectively. Wilcoxon signed-rank, analysis of variance, and Cuzick trend tests were used to assess for overprescription and changes over time in opioid prescribing and consumption. RESULTS: We included 2239 patients in our cohort. The amount prescribed (median [IQR]: 30 [24-45] versus 18 [12-30], P < 0.001) and consumed (median [IQR]: 12 [7-20] versus 8 [3-15], P < 0.001) each decreased between the first and last quarter studied. Academic hospitals prescribed fewer opioids than nonacademic hospitals (median [IQR]: 24[15-40] versus median [IQR]: 30 [20-45], P < 0.001). There was no difference in the quantity of opioids consumed between patients treated at academic and nonacademic facilities (median [IQR]: 10[3-19] versus 10.5 [4-20], P = 0.08). Patients consumed a median of 42% of the opioids prescribed, and there was no significant trend in the percent consumed over time (P = 0.8). CONCLUSIONS: Patients used far fewer opioids than prescribed after common adult general surgery procedures. When surgeons were provided with patient consumption data, the number of opioids prescribed decreased significantly.
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Analgésicos Opioides/administração & dosagem , Implementação de Plano de Saúde/normas , Dor Pós-Operatória/tratamento farmacológico , Padrões de Prática Médica/organização & administração , Melhoria de Qualidade , Adulto , Idoso , Analgésicos Opioides/efeitos adversos , Feminino , Humanos , Hidrocodona/administração & dosagem , Hidrocodona/efeitos adversos , Masculino , Uso Excessivo dos Serviços de Saúde/prevenção & controle , Uso Excessivo dos Serviços de Saúde/estatística & dados numéricos , Pessoa de Meia-Idade , Epidemia de Opioides/prevenção & controle , Manejo da Dor/métodos , Manejo da Dor/normas , Manejo da Dor/estatística & dados numéricos , Medição da Dor/estatística & dados numéricos , Dor Pós-Operatória/diagnóstico , Dor Pós-Operatória/etiologia , Medidas de Resultados Relatados pelo Paciente , Cuidados Pós-Operatórios/normas , Cuidados Pós-Operatórios/estatística & dados numéricos , Guias de Prática Clínica como Assunto , Padrões de Prática Médica/normas , Padrões de Prática Médica/estatística & dados numéricos , Estudos Prospectivos , Procedimentos Cirúrgicos Operatórios/efeitos adversos , ComprimidosRESUMO
BACKGROUND: Excess opioid use after surgery contributes to opiate misuse and diversion. Understanding opioid prescribing and utilization patterns after sinonasal surgery is critical in designing effective practice protocols. In this study we aim to identify factors associated with variable opioid usage and further delineate optimal prescription patterns for sinonasal surgery. METHODS: All patients undergoing sinonasal surgery within a single health-care system from March 2017 to August 2018 were sent electronic postoperative surveys. Data were collected on the amount of opioid required, pain control, presurgical opiate use, and narcotic disposal. Additional data collected from the electronic medical record included demographics, type of surgery performed, and total amount of opioid prescribed, including refills. RESULTS: Three-hundred sixty four patients were included. A mean number of 25.3 tablets were prescribed per patient, yet the mean taken was just 11.8 tablets. Excess opioids were prescribed 84.9% of the time with a mean excess narcotic in oral morphine equivalents of 152.5. Among patients, 11.8% reported using no opioids, whereas 52.1% used <50% and 36.1% used >50% of their narcotic prescription. Patients used 9.3% of their full prescription and only 2.6% required a refill. The amount used was not associated with complexity of endoscopic sinus surgery, type of opiate prescribed, gender, distance living from hospital, or current opioid usage before surgery (p > 0.05). The addition of septoplasty and/or turbinoplasty was associated with variation in opioid usage (p < 0.001). A total of 76.1% of patients incorrectly discarded/stored excess opiates. CONCLUSION: Opioids are overprescribed after sinonasal surgery. The amount of postoperative opiate prescribed should be greatly reduced and may be based on the specific procedures performed. Improved patient education regarding disposal of excess narcotics may help to curtail future opioid diversion.
Assuntos
Analgésicos Opioides/uso terapêutico , Prescrições de Medicamentos/estatística & dados numéricos , Procedimentos Cirúrgicos Nasais/estatística & dados numéricos , Padrões de Prática Médica/estatística & dados numéricos , Adulto , Armazenamento de Medicamentos/estatística & dados numéricos , Feminino , Humanos , Masculino , Adesão à Medicação/estatística & dados numéricos , Pessoa de Meia-Idade , Dor Pós-Operatória/tratamento farmacológico , Dor Pós-Operatória/prevenção & controle , Período Perioperatório , Inquéritos e QuestionáriosRESUMO
BACKGROUND: In the setting of a national opioid epidemic there are concerns about routine overprescription of opioids postoperatively in both children and adults, which introduces excess opioids into the community. PURPOSE: We sought to examine current opioid prescribing practices by surgeons and consumption of prescribed opioids by pediatric surgical patients following discharge. METHODS: Starting in January 2017 we began an emailed survey for all postoperative patients in a 23-hospital system about the opioids they were prescribed and consumed following discharge. They were then asked if their pain was controlled. Responses of pediatric patients (age 10-18) were examined. FINDINGS: Data from 277 patients were analyzed. After surgical procedures, patients were prescribed significantly more opioids (given in hydrocodone 5â¯mg equivalents) than they consumed: for appendectomy (median 10 vs. 2) cholecystectomy (12 vs. 5), hernia repair (20 vs. 14), tonsillectomy (30 vs. 17), sinus surgery (30 vs. 5), septoplasty (27 vs. 9.5), knee arthroscopy (30 vs. 12.5), open reduction and internal fixation (ORIF) of the hand and wrist (20 vs. 8.5), and ORIF of the foot and ankle (27 vs. 13.5). The majority (84%) of patients agreed or strongly agreed with the statement that their pain was controlled. Of patients with excess opioids, 64% reported keeping them in their home. CONCLUSIONS: Providers prescribed more opioid tablets than were used by patients. Despite using fewer tablets, patients reported good pain control. Current prescribing practices contribute to excess opioids in the community and represent an opportunity to alter the current epidemic. LEVEL OF EVIDENCE: III.
Assuntos
Uso Excessivo dos Serviços de Saúde/estatística & dados numéricos , Manejo da Dor/estatística & dados numéricos , Dor Pós-Operatória/tratamento farmacológico , Analgésicos Opioides , Criança , Humanos , Padrões de Prática Médica/estatística & dados numéricos , CirurgiõesRESUMO
INTRODUCTION: Neoadjuvant therapy (NT) is the standard of care for clinical stage II-III rectal adenocarcinoma, but utilization remains suboptimal. We aimed to determine the underlying reasons for omission of local staging and NT. METHODS: We conducted a retrospective study of patients with clinical stage II-III or undocumented clinical stage/pathologic stage II-III rectal adenocarcinoma who were treated in 2010-2016 in one of nine Intermountain Healthcare hospitals. The outcomes of omission of local staging and NT were examined with multivariable models. Risk- and reliability-adjusted rates of local staging and NT were calculated for surgeons who treated ≥ 3 patients. Pathologic and long-term outcomes were examined after excluding patients who were not resected or who underwent local excision (N = 11). RESULTS: Local staging was omitted in 43/240 (17.9%) patients and NT was omitted in 41/240 (17.1%). The strongest risk factors for local staging and NT omission were upper rectal tumors and surgeons who treated ≤ 3 cases/year. Thirty-six of 41 (87.8%) cases of omitted NT had local staging omitted. Adjusted surgeon-specific local staging rates varied 1.6-fold (56.3-92.4%) and NT rates varied 2.8-fold (34.1-97.1%). Surgeon local staging and NT rates were strongly correlated (r = 0.92). NT was associated with lower rates of positive circumferential radial margins (7.9 vs. 20.0%; P = 0.02), node positivity (33.3 vs. 55.0%; P = 0.01), and local recurrences (7.6 vs. 14.9% at 5 years; P = 0.0176). CONCLUSIONS: NT omission should be understood as a consequence of surgeon failure to perform local staging in most cases. Quality improvement efforts should focus on improving utilization of local staging.
Assuntos
Adenocarcinoma/patologia , Adenocarcinoma/terapia , Quimiorradioterapia Adjuvante/estatística & dados numéricos , Terapia Neoadjuvante/estatística & dados numéricos , Padrões de Prática Médica/estatística & dados numéricos , Neoplasias Retais/patologia , Neoplasias Retais/terapia , Adenocarcinoma/mortalidade , Adulto , Idoso , Idoso de 80 Anos ou mais , Quimiorradioterapia Adjuvante/normas , Feminino , Seguimentos , Disparidades em Assistência à Saúde/estatística & dados numéricos , Humanos , Masculino , Margens de Excisão , Pessoa de Meia-Idade , Terapia Neoadjuvante/normas , Recidiva Local de Neoplasia/epidemiologia , Recidiva Local de Neoplasia/etiologia , Recidiva Local de Neoplasia/prevenção & controle , Estadiamento de Neoplasias , Padrões de Prática Médica/normas , Utilização de Procedimentos e Técnicas/normas , Utilização de Procedimentos e Técnicas/estatística & dados numéricos , Protectomia , Garantia da Qualidade dos Cuidados de Saúde , Indicadores de Qualidade em Assistência à Saúde/estatística & dados numéricos , Neoplasias Retais/mortalidade , Reprodutibilidade dos Testes , Estudos Retrospectivos , Cirurgiões/normas , Cirurgiões/estatística & dados numéricos , Resultado do Tratamento , Estados Unidos/epidemiologiaRESUMO
BACKGROUND: Utilization of multimodality therapy for clinical stage I-II pancreatic ductal adenocarcinoma is associated with meaningful prolongation of survival. Although the qualitative existence of disparities in treatment utilization by socioeconomic status and race/ethnicity is well documented, the absolute magnitudes of these disparities have not been previously quantified. METHODS: The exposures in this retrospective cohort study of the 2010-2015 National Cancer Database were a 7-value area-level socioeconomic status index and race/ethnicity. Main outcomes were surgery, chemotherapy, and multimodality therapy (surgery and chemotherapy). Adjusted rate differences were calculated after logistic regression. Models excluded intermediate variables. Overall survival was evaluated in unadjusted and adjusted analyses. RESULTS: Of 43,760 patients, 63.4% underwent surgery. Of 39,808 patients without chemotherapy contraindications, refusal, or missing data, 75.1% received chemotherapy and 51.4% received multimodality therapy. Adjusted rate differences for utilization of surgery, chemotherapy, and multimodality therapy in the lowest socioeconomic status patients were -10.0 (95% confidence interval [CI] -12.4 to -7.5), -12.7 (95% CI -16.3 to -9.1), and -15.4 (95% CI -18.8 to -12.0), respectively, versus the highest socioeconomic status patients. Adjusted rate differences for multimodality therapy utilization in non-Hispanic Black and Hispanic patients were -10.1 (95% CI -13.6 to -6.7) and -11.8 (95% CI -14.3 to -9.2), respectively, versus non-Hispanic White patients. Median overall survival increased in a graded fashion from 14.1 (95% CI 13.4-14.8) months in the lowest socioeconomic status patients to 20.2 months (95% CI 19.6-20.8) in the highest socioeconomic status patients. Survival differences were attenuated but not eliminated in multivariable Cox models. CONCLUSION: Socioeconomic status and race/ethnicity are more powerful determinants of whether patients receive treatment for clinical stage I-II pancreatic ductal adenocarcinoma than previously appreciated. Nationwide quality improvement efforts aimed at addressing these inequities are warranted.