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Neonatal surgery in low- vs. high-volume institutions: a KID inpatient database outcomes and cost study after repair of congenital diaphragmatic hernia, esophageal atresia, and gastroschisis

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Abstract

Background/purpose

The volume–outcome relationship and optimal surgical volumes for repair of congenital anomalies in neonates is unknown.

Methods

A retrospective study of infants who underwent diaphragmatic hernia (CDH), gastroschisis (GS), and esophageal atresia/tracheoesophageal fistula (EA/TEF) repair at US hospitals using the Kids’ Inpatient Database 2009–2012. Distribution of institutional volumes was calculated. Multi-level logistic/linear regressions were used to determine the association between volume and mortality, length of stay, and costs.

Results

Total surgical volumes were 1186 for CDH, 1280 for EA/TEF, and 3372 for GS. Median case volume per institution was three for CDH and EA/TEF, and four for GS. Hospitals with annual case volumes ≥ 75th percentile were considered high volume. Approximately, half of all surgeries were performed at low-volume hospitals. No clinically meaningful association between volume and outcomes was found for any procedure. Median cost was greater at high- vs. low-volume hospitals [CDH: $165,964 (p < 0.0001) vs. $104,107, EA/TEF: $85,791 vs. $67,487 (p < 0.006), GS: $83,156 vs. $72,710 (p < 0.0009)].

Conclusions

An association between volume and outcome was not identified in this study using robust outcome measures. The cost of care was higher in high-volume institutions compared to low-volume institutions.

Level of evidence

III

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Abbreviations

CDH:

Congenital diaphragmatic hernia

EA/TEF:

Esophageal atresia with/without tracheoesophageal fistula

GS:

Gastroschisis

NICU:

Neonatal intensive care unit

KID:

Kids’ Inpatient Database

LOS:

Length of stay

ECMO:

Extracorporeal membrane oxygenation

References

  1. Barfield WD, Papile L, Baley JE, Benitz W, Cummings J, Carlo WA et al (2012) Levels of neonatal care. Pediatr Engl Ed. 130(3):587

    Google Scholar 

  2. Halm EA, Lee C, Chassin MR (2002) Is volume related to outcome in health care? A systematic review and methodologic critique of the literature. Ann Intern Med 137(6):511–520

    Article  Google Scholar 

  3. Factsheet: evidence-based hospital referral. [Internet].: The Leapfrog Group. [cited 7 Mar, 2016.]. Available from: https://www.leapfroggroup.org/media/file/FactSheet_EBHR.pdf. Accessed 30 Mar 2019

  4. Healthcare Cost and Utilization Project (HCUP). [Internet].: Kids' inpatient database (KID).; 2014 [cited 31 December 2014]. Available from: https://www.hcup-us.ahrq.gov/kidoverview.jsp. Accessed 30 Mar 2019

  5. Hosmer DW, Lemeshow S (2000) Applied logistic regression, 2nd edn. Wiley, New York

    Book  Google Scholar 

  6. McAteer JP, LaRiviere CA, Drugas GT, Abdullah F, Oldham KT, Goldin AB (2013) Influence of surgeon experience, hospital volume, and specialty designation on outcomes in pediatric surgery: a systematic review. JAMA Pediatr 167(5):468–475

    Article  Google Scholar 

  7. Grushka JR, Laberge J, Puligandla P, Skarsgard ED (2009) Effect of hospital case volume on outcome in congenital diaphragmatic hernia: the experience of the Canadian pediatric surgery network. J Pediatr Surg 44(5):873–876

    Article  Google Scholar 

  8. Birkmeyer JD, Stukel TA, Siewers AE, Goodney PP, Wennberg DE, Lucas FL (2003) Surgeon volume and operative mortality in the United States. N Engl J Med 349(22):2117–2127

    Article  CAS  Google Scholar 

  9. Pieper D, Mathes T, Neugebauer E, Eikermann M (2013) State of evidence on the relationship between high-volume hospitals and outcomes in surgery: a systematic review of systematic reviews. J Am Coll Surg 216(5):1015–1025.e18

    Article  Google Scholar 

  10. Birkmeyer JD, Siewers AE, Finlayson EV, Stukel TA, Lucas FL, Batista I et al (2002) Hospital volume and surgical mortality in the United States. N Engl J Med 346(15):1128–1137

    Article  Google Scholar 

  11. Hannan EL, Racz M, Kavey RE, Quaegebeur JM, Williams R (1998) Pediatric cardiac surgery: the effect of hospital and surgeon volume on in-hospital mortality. Pediatrics 101(6):963–969

    Article  CAS  Google Scholar 

  12. Hong CR, Fullerton BS, Han SM, Morrow KA, Edwards EM, Soll RF et al (2019) Impact of disease-specific volume and hospital transfer on outcomes in gastroschisis. J Pediatr Surg 54(1):65–69

    Article  Google Scholar 

  13. Dylkowski D, Dave S, McClure JA, Welk B, Winick-Ng J, Jones S (2018) Repair of congenital esophageal atresia with tracheoesophageal fistula repair in Ontario over the last 20 years: volume and outcomes. J Pediatr Surg 53(5):925–928

    Article  Google Scholar 

  14. Wang B, Tashiro J, Allan BJ, Sola JE, Parikh PP, Hogan AR et al (2014) A nationwide analysis of clinical outcomes among newborns with esophageal atresia and tracheoesophageal fistulas in the United States. J Surg Res 190(2):604–612

    Article  Google Scholar 

  15. Sulkowski JP, Cooper JN, Lopez JJ, Jadcherla Y, Cuenot A, Mattei P et al (2014) Morbidity and mortality in patients with esophageal atresia. Surgery 156(2):483–491

    Article  Google Scholar 

  16. Sacks GD, Ulloa JG, Shew SB (2016) Is there a relationship between hospital volume and patient outcomes in gastroschisis repair? J Pediatr Surg 51(10):1650–1654

    Article  Google Scholar 

  17. Baird R, Eeson G, Safavi A, Puligandla P, Laberge J, Skarsgard ED et al (2011) Institutional practice and outcome variation in the management of congenital diaphragmatic hernia and gastroschisis in Canada: a report from the Canadian pediatric surgery network. J Pediatr Surg 46(5):801–807

    Article  Google Scholar 

  18. Kane JM, Harbert J, Hohmann S, Pillai S, Behal R, Selip D et al (2015) Case volume and outcomes of congenital diaphragmatic hernia surgery in academic medical centers. Am J Perinatol 32(09):845–852

    Article  Google Scholar 

  19. O'Neill JA Jr, Gautam S, Geiger JD, Ein SH, Holder TM, Bloss RS et al (2000) A longitudinal analysis of the pediatric surgeon workforce. Ann Surg 232(3):442–453

    Article  Google Scholar 

  20. Sømme S, Bronsert M, Kempe A, Morrato E, Ziegler M (2012) Alignment of training curriculum and surgical practice: implications for competency, manpower, and practice modeling. Eur J Pediatric Surg 22(01):074–79

    Article  Google Scholar 

  21. Abdullah F, Salazar JH, Gause CD, Gadepalli S, Biester TW, Azarow KS et al (2016) Understanding the operative experience of the practicing pediatric surgeon: implications for training and maintaining competency. JAMA Surg 151(8):735–741

    Article  Google Scholar 

  22. Oldham KT (2014) Optimal resources for children's surgical care. J Pediatr Surg 49(5):667–677

    Article  Google Scholar 

  23. Berry JG, Lieu TA, Forbes PW, Goldmann DA (2007) Hospital volumes for common pediatric specialty operations. Arch Pediatr Adolesc Med 161(1):38–43

    Article  Google Scholar 

  24. Smith ER, Butler WE, Barker FG (2004) Craniotomy for resection of pediatric brain tumors in the United States, 1988 to 2000: effects of provider caseloads and progressive centralization and specialization of care. Neurosurgery 54(3):553–565

    Article  Google Scholar 

  25. Kim W, Wolff S, Ho V (2016) Measuring the volume-outcome relation for complex hospital surgery. Appl Health Econ Health Policy 14(4):453–464

    Article  Google Scholar 

  26. Jacobs JP, Mayer JE Jr, Mavroudis C, O’Brien SM, Austin EH III, Pasquali SK et al (2017) The Society of thoracic surgeons congenital heart surgery database: 2017 update on outcomes and quality. Ann Thorac Surg. 103(3):699–709

    Article  Google Scholar 

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Funding

The final draft of the manuscript was written by Stig Sømme. Funding was received from the Children’s Hospital Colorado Center for Research in Outcomes for Children’s Surgery (ROCS).

Author information

Authors and Affiliations

  1. Division of Pediatric Surgery, Children’s Hospital Colorado, Aurora, CO, 80045, USA

    Stig Sømme, Niti Shahi, Lisa McLeod & Moritz M. Ziegler

  2. Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA

    Stig Sømme, Niti Shahi & Moritz M. Ziegler

  3. Adult and Child Center for Health Outcomes Research and Delivery Science (ACCORDS), University of Colorado School of Medicine, Aurora, CO, USA

    Michelle Torok & Beth McManus

Authors
  1. Stig Sømme
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  2. Niti Shahi
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  3. Lisa McLeod
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  4. Michelle Torok
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  5. Beth McManus
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  6. Moritz M. Ziegler
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Corresponding author

Correspondence to Niti Shahi.

Ethics declarations

Ethical approval

All the procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Informed consent

The study was evaluated and approved by the Colorado Multiple Institution Review Board (COMIRB), and a waiver of informed consent as obtained due to the retrospective nature of the study and the use of the national KID.

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Appendix A.

Appendix A.

Study definitions

Congenital diaphragmatic hernia (CDH)

Age at admission 0–28 days, LOS > 7 days

Diagnosis code: 756.6 and

Procedure codes: 53.71 or 53.75 or 53.84 or 53.72 or 53.80 or 34.82 or 34.84 or 53.83

Tracheoesophageal fistula (TEF)

Age at admission 0–28 days, LOS > 7 days

Diagnosis codes: 750.3 or 530.84 and

Procedure code: 31.73

Gastroschisis (GS):

Age at admission 0–28 days, LOS > 7 days

Diagnosis codes: 756.73 or 756.79 and

Procedure code: 54.71

Patent ductus arteriosus dx and surgery indicator variable

Diagnosis code: 747.0: 1 and

Procedure code: 38.85

Congenital heart disease indicator variable

Diagnosis codes: 746.0 or 746.00 or 746.01 or 746.02 or 746.09 or 746.1 or 746.2 or 746.3 or 746.4 or 746.5 or 746.6 or 746.7 or 746.8 or 746.81 or 746.82 or 746.83 or 746.84 or 746.85 or 746.86 or 746.87 or 746.89 or 746.9

Prematurity indicator variable

Diagnosis codes = “ ≤ 28 weeks”: 765.21 or 765.22 or 765.23 or 765.24

Diagnosis codes = “29–32 weeks”: 765.25 or 765.26

Diagnosis codes = “33–36 weeks”: 765.27 or 765.28

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Sømme, S., Shahi, N., McLeod, L. et al. Neonatal surgery in low- vs. high-volume institutions: a KID inpatient database outcomes and cost study after repair of congenital diaphragmatic hernia, esophageal atresia, and gastroschisis. Pediatr Surg Int 35, 1293–1300 (2019). https://doi.org/10.1007/s00383-019-04525-x

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  • DOI: https://doi.org/10.1007/s00383-019-04525-x

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