Health Outcome
Health outcomes and the healthcare and societal cost of optimizing pediatric surgical care in the United States

https://doi.org/10.1016/j.jpedsurg.2018.10.102Get rights and content

Abstract

Background

There is a movement to ensure that pediatric patients are treated in appropriately resourced hospitals through the ACS Children’s Surgery Verification (CSV) program. The objective of this study was to assess the potential difference in care provision, health outcomes and healthcare and societal costs after implementation of the CSV program.

Methods

All 2011 inpatient admissions for selected complex pediatric patients warranting treatment at a hospital with Level I resources were evaluated across 6 states. Multivariate regressions were used to analyze differences in healthcare outcomes (postoperative complications including death, length of stay, readmissions and ED visits within 30 days) and costs by CSV level. Recycled predictions were used to estimate differences between the base case scenario, where children actually received care, and the optimized scenario, where all children were theoretically treated at Level I centers.

Results

8,006 children (mean age 3.06 years, SD 4.49) met inclusion criteria, with 45% treated at Level I hospitals, 30% at Level II and 25% at Level III. No statistically significant differences were observed in healthcare outcomes. Readmissions within 30 days were higher at Level II compared to Level I centers (adjusted IRR 1.61; 95% CI 1.11, 2.34), with an estimated 24 avoidable readmissions per 1000 children if treatment were shifted from Level II to Level I centers. Overall, costs per child were not significantly different between the base case and the optimized scenario.

Conclusion

Many complex surgical procedures are being performed at Level II/III centers. This study found no statistically significant increase in healthcare or societal costs if these were performed instead at Level I centers under the optimized scenario. Ongoing evaluation of efforts to match institutional resources with individual patient needs is needed to optimize children’s surgical care in the United States.

Level of evidence

II.

Section snippets

Data sources

The 2011 state-specific Healthcare Cost and Utilization Project (HCUP) family of databases for Florida, Iowa, Nebraska, New York, Utah, and Vermont was used to identify all children less than 18 years of age who had complex inpatient surgical procedures [13], [14]. These six states were chosen to estimate the potential impact of this optimization effort on varied geographic and demographic regions in the U.S. The 2011 data were the most recent source for inpatient and emergency department (ED)

Provision of care

There were 8006 children treated for selected conditions judged to require the resources of an ACS Level I center. Among those children, 54.6% received their care outside of a Level I center: 2391(30%) received care at a Level II center and 2005 (24.6%) at a Level III center (Table 1). Nearly half (n = 3820, 47.7%) of all children treated were less than one year of age, and 55.3% (n = 2093) of these infants were treated outside of a Level I center. Children treated at Level I centers were more

Discussion

This study offers a unique medical and social perspective on the potential impact of the ACS-CSV verification program on healthcare outcomes and the cost of children’s surgical care in the United States. Our findings suggest that half of surgically complex children with needs meriting care at a Level I center are currently treated at Level II or III centers. Our data further suggest that treating children in this cohort in the optimized scenario at Level I centers would not significantly

Conclusion

This study demonstrates that many complex children’s surgical procedures are currently performed at hospitals with limited pediatric resources. Our study did not identify measurable differences in healthcare outcomes, healthcare costs, or societal costs between centers, although, over time, with additional data evaluating the CSV process, these findings may change. These data suggest that optimizing families to a Level I center instead of the Level II or III center where they are currently

Acknowledgments

The authors would like to acknowledge the participating investigators, Arianna Delsman, BA and Tony Escobar, MD for their time, hard work, and dedication to this project.

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  • Cited by (8)

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      The main limitation of this survey was recruitment bias, with an overall response rate of 50% and over-representation of university centers (47% of respondents), even if the responses were collected from four different regions. Also, surveying French private sector hospitals on children's admission and the quality of care in surgery departments would be useful [9]. Because the European Charter of the Rights of Children in Hospital dates back to 1988, it could be supplemented with recommendations on more topical issues.

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    Funding: This work was supported by a grant from the Children’s Hospital Association to Dr. Goldin. Dr. Flynn-O’Brien received fellowship support from the National Institute of Child Health and Human Development [grant number T32-HD057822]. The content, findings and conclusions in this report are solely the responsibility of the authors and do not necessarily represent the official views or position of the National Institutes of Health or the Children’s Hospital Association.

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