Katherine T Flynn-O'Brien1, Morgan K Richards2, Davene R Wright3, Frederick P Rivara4, Wren Haaland5, Leah Thompson6, Keith Oldham7, Adam Goldin8. 1. Department of Surgery, Children's Hospital of Wisconsin, Division of Pediatric Surgery, Pediatric Surgery, 999 North 92(nd) Street, C320, Milwaukee, WI 53226. Electronic address: kflynnobrien@mcw.edu. 2. Department of Surgery, Children's Healthcare of Atlanta, Division of Pediatric Surgery, Pediatric Surgery, 1405 Clifton Rd NE, Atlanta, GA 30322. Electronic address: Morgan.kate.richards@emory.edu. 3. Department of Pediatrics, University of Washington and Seattle Children's Research Institute, Center for Child Health, Behavior, and Development, Division of General Pediatrics, 2001 Eighth Ave, Suite 400, Seattle, WA 98121, USA. Electronic address: davene.wright@seattlechildrens.org. 4. Department of Pediatrics, University of Washington, Seattle Children's Research Institute, Center for Child Health, Behavior and Development, Division of General Pediatrics, Harborview Injury Prevention and Research Center, Box 359960, 325 Ninth Ave, Seattle, WA 98104, USA. Electronic address: fpr@uw.edu. 5. Seattle Children's Research Institute, Center for Child Health, Behavior, and Development, 2001 Eighth Ave, Suite 400, Seattle, WA 98121, USA. Electronic address: wren.haaland@seattlechildrens.org. 6. Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA. Electronic address: leah_thompson@hms.harvard.edu. 7. Children's Hospital of Wisconsin, Medical College of Wisconsin, 999 North 92(nd) Street, C320, Milwaukee, WI 53226. Electronic address: koldham@chw.org. 8. Department of Surgery, Seattle Children's Hospital, Division of Pediatric General and Thoracic Surgery, Seattle Children's Hospital, Department of Surgery, University of Washington School of Medicine, 4800 Sand Point Way NE, Seattle, WA 98105, USA. Electronic address: adam.goldin@seattlechildrens.org.
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.
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.
Authors: Ellen J MacKenzie; Frederick P Rivara; Gregory J Jurkovich; Avery B Nathens; Katherine P Frey; Brian L Egleston; David S Salkever; Daniel O Scharfstein Journal: N Engl J Med Date: 2006-01-26 Impact factor: 91.245
Authors: Shawn D Safford; Ricardo Pietrobon; Kristine M Safford; Henrique Martins; Michael A Skinner; Henry E Rice Journal: J Pediatr Surg Date: 2005-06 Impact factor: 2.545