Examining length of stay after commonly performed surgical procedures in ACS NSQIP pediatric

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Association for Academic Surgery

Examining length of stay after commonly performed surgical procedures in ACS NSQIP pediatric Dominic Papandria, MD,a Yuri V. Sebastia˜o, MPH, PhD,a Katherine J. Deans, MD, MHSc,a,b Karen A. Diefenbach, MD,a and Peter C. Minneci, MD, MHSca,b,* a

Department of Surgery, Nationwide Children’s Hospital, Columbus, Ohio Center for Surgical Outcomes Research, The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio

b

article info

abstract

Article history:

Background: The objective of this study was to identify ranges of postoperative length of

Received 20 February 2018

stay (LOS) for common pediatric procedures using a large multi-institutional database.

Received in revised form

Materials and methods: A retrospective analysis of the most frequently performed general

2 May 2018

surgical procedures in the ACS-NSQIP Pediatric (2013-2015) was performed. These included

Accepted 24 May 2018

laparoscopic appendectomy (LA), laparoscopic cholecystectomy, laparoscopic gastrostomy,

Available online xxx

laparoscopic esophagogastric fundoplication (LF), thoracoscopic repair of pectus excavatum (TPE), open appendectomy (OA), enterostomy closure (OEC), gastrostomy closure

Keywords:

(OGC), and bowel resection (OBR). Patients aged <6 mo or >18 y, operations with major

Pediatric surgery

concurrent procedures, same-day discharges, operations performed >2 d after admission,

Length of stay

and inpatient deaths were excluded. Postoperative LOS was examined for each procedure,

Appendectomy

including multivariable analysis of risk factors for postoperative LOS > 75th percentile.

Cholecystectomy

Results: A total of 29,557 cases were identified and included procedure subgroups ranging from

Performance benchmarking

505 (OBR) to 19,260 (LA) cases. Procedure-specific median postoperative LOS (75th percentile; 90th percentile) were LA 1 d (2 d; 5 d); laparoscopic cholecystectomy 1 d (1 d; 2 d); laparoscopic gastrostomy 2 d (2 d, 4 d); laparoscopic fundoplication 3 d (4 d, 6 d); thoracoscopic repair of pectus excavatum 4 d (5 d, 6 d); OA 3 d (6 d, 9 d); OEC 4 d (6 d, 10 d); OGC 1 d (1 d, 2 d); and OBR 6 d (10 d, 20 d). Preoperative risk factors for high postoperative LOS varied by procedure and included patient demographics, admission factors, case characteristics, and comorbidities. Conclusions: The range of postoperative LOS and risk factors for high postoperative LOS for commonly performed procedures varied considerably. These results may be a useful reference for benchmarking and resource utilization analyses at the institutional and health systems levels. ª 2018 Elsevier Inc. All rights reserved.

* Corresponding author. Center for Surgical Outcomes Research, The Research Institute at Nationwide Children’s Hospital, 700 Children’s Drive, FB 3A.3, Columbus, OH 43205. Tel.: þ1 614 722 3066; fax: þ1 614 722 6980. E-mail address: [email protected] (P.C. Minneci). 0022-4804/$ e see front matter ª 2018 Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jss.2018.05.054

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papandria et al  length of stay after pediatric surgery

Introduction Postoperative inpatient length of stay (LOS) has long been posited as a driver of health-care costs and is an objective metric commonly reported in the surgical literature. LOS is frequently used in comparative effectiveness research and health-care quality improvement initiatives in general1-4 and pediatric surgery.5 Despite broad agreement that decreasing LOS confers substantial benefits with respect to hospital charges, resource utilization, and patient and caregiver satisfaction, little is known regarding baseline LOS across hospitals with respect to particular procedures. Lacking a reference data set, it is difficult to compare results of surgical practice across centers with respect to LOS if they are not participating in an ongoing multi-institutional quality improvement program. The present study examines LOS data after common pediatric surgical procedures using a multicenter quality improvement database. The goal was to identify ranges of postoperative LOS for common pediatric procedures which could potentially be used for benchmarking and resource utilization analyses at the institutional and health systems levels.

total procedure codes was excluded. The remaining codes were examined and grouped into three categories: rare (<4 occurrences within the data set), blacklist (expected to increase LOS), and whitelist (not expected to significantly impact LOS when paired with the primary CPT). Records with rare and blacklist codes were included as other or concurrent procedures were excluded. The procedure code sets and categorization groups are detailed in online Supplementary Tables S1 and S2. The following were the nine most common procedure categories: laparoscopic appendectomy (LA), laparoscopic cholecystectomy (LC), laparoscopic gastrostomy (LG), laparoscopic esophagogastric fundoplication, thoracoscopic repair of pectus excavatum, open appendectomy, enterostomy closure, gastrostomy closure, and open bowel resection. These were then selected for further analysis, and all remaining records were excluded, as were records with inpatient deaths and those with discharge on the day of surgery (see Table 1 for a summary of inclusion and exclusion

Table 1 e Inclusion and exclusion criteria. Data set

Methods Data source Data were obtained from the American College of Surgeons’ National Surgical Quality Improvement Program Pediatric (ACS NSQIP Pediatric) for the period of 2013-2015. The ACS NSQIP Pediatric collects patient-level clinical data, including demographics, comorbidities, laboratory values, and 30-d postoperative outcomes for surgical procedures performed on patients younger than 18 y from 109 participating institutions.6 Cases are systematically sampled based on an 8-d cycle (35 procedures per cycle) across all specialties. To ensure high reliability and validity, data elements are rigorously defined and collected by trained surgical clinical reviewers, and random audits are performed to check for definition compliance.7

Study population

ACS NSQIP Pediatric PUF, (2013-2015)

Inclusion criteria

Exclusion criteria

Procedures

Procedures

Laparoscopic: appendectomy, cholecystectomy, gastrostomy, fundoplication Thoracoscopic: repair of pectus excavatum

Concurrent/other procedures: rare or unrelated major abdominal/ thoracic

Open: appendectomy, enterostomy closure, gastrostomy closure, bowel resection

Total procedure codes: >3

Hospitalization

The initial eligible study population comprised of patients aged between 6 mo and 17 y, admitted from home or the emergency room (ER), for whom the primary procedure was performed within 2 d of admission, and defined among the following surgical specialties: “general surgery,” “pediatric surgery,” “cardiovascular-thoracic,” and “pediatric cardiovascular-thoracic”. To focus on commonly performed surgical procedures, we identified procedures with a minimum of 100 cases recorded within the data set. These were then collapsed into groups using American Medical Association Current Procedural Terminology codes (CPT) to define discrete procedure categories. A series of exclusion criteria were then imposed by examining both the primary CPT as well as those recorded for other and concurrent procedures performed under the same anesthetic. Any record with greater than three

Timing: procedures performed >2 d after admission

Admitted from: home or emergency department.

Surgeon specialty General surgery, pediatric surgery, cardiovascularthoracic, or pediatric cardiovascularthoracic

Hospitalization Disposition: discharge on day of surgery or death as inpatient Demographics Age <6 mo or >17 y

ACS NSQIP ¼ American College of Surgeons National Surgical Quality Improvement Program; PUF ¼ Participant Use Data File.

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Table 2 e Preoperative characteristics in the study population. Variable

n (%)

Age group >6 to <12 mo

1027 (3.5)

1-2 y

1796 (6.1)

3-5 y

2982 (10.1)

6-7 y 8-12 y 13-18 y Female Hispanic ethnicity

3062 (10.4) 11,126 (37.6) 9564 (32.4) 12,705 (43.0) 6671 (22.6)

Race White Black Asian Other/unknown Admitted to emergency room

21,667 (73.3) 2965 (10.0) 788 (2.7) 4137 (14.0) 20,098 (68.0)

Table 2 e (continued ) Variable

n (%)

Bone marrow transplant

36 (0.1)

Current pneumonia

22 (0.1)

Renal insufficiency{

22 (0.1)

Do not resuscitate (DNR) status

11 (0.0)

BMI ¼ body mass index. * SIRS/Sepsis/Septic shock. y GI disease: biliary/liver/pancreatic disease, or esophageal/gastric/ intestinal disease. z Pulmonary disease: ventilator dependent, history of asthma, cystic fibrosis, bronchopulmonary dysplasia/chronic lung disease, oxygen support, tracheostomy, or structural pulmonary/airway abnormalities. x Neurologic disease: CVA/stroke or traumatic/acquired brain injury with resulting neurological deficit, Tumor involving CNS, seizure disorder, cerebral palsy, structural CNS abnormality, neuromuscular disorder, or intraventricular hemorrhage (IVH) of grade 1. k Hematologic disease: bleeding disorders or hematologic disorder. { Renal insufficiency: acute renal failure or currently on dialysis.

Case type Elective

9889 (33.5)

Urgent

5832 (19.7)

Emergent

13,836 (46.8)

American Society of Anesthesiologists class 1eNormal

11,466 (38.8)

2eMild disease

13,705 (46.4)

3eSevere disease 4/5eLife-threatening/moribund

4184 (14.2) 202 (0.7)

Wound class Clean

2118 (7.2)

Clean/contaminated

10,768 (36.4)

Contaminated

10,685 (36.2)

Dirty/infected Premature birth (36 wk)

5986 (20.3) 2057 (7.0)

BMI/weight for height percentile Normal/under (<85)

15,843 (53.6)

Overweight (85-94)

3501 (11.8)

Obese (95)

4780 (16.2)

Unknown

5433 (18.4)

Comorbidities Systemic sepsis w/n 48 h before operation*

9874 (33.4)

Diabetes mellitus

6381 (21.6)

Gastric/intestinal diseasey

4952 (16.8)

Pulmonary diseasez

3183 (10.8)

Developmental delay

2699 (9.1)

Neurologic diseasex

2362 (8.0)

Hematologic diseasek

770 (2.6)

Major/severe cardiac risk factor

698 (2.4)

Immune disease/immunosuppressant use

226 (0.8)

Solid organ transplant

62 (0.2) (continued)

criteria). In the analysis, procedures were classified as minimally invasive surgery (MIS; LA, LC, LG, laparoscopic fundoplication (LF), and thoracoscopic pectus repair) or open (open appendectomy, enterostomy closure, gastrostomy closure, and bowel resection).

Statistical analysis The primary outcome measure was postoperative inpatient LOS (defined as number of days from primary procedure to discharge from hospital). Percentiles were initially used to describe postoperative length of stay, as a continuous variable, by procedure. LOS was then dichotomized into normal and high to examine patient preoperative risk factors for high LOS. For each procedure, high LOS cases were defined as patients who had postoperative LOS greater than the 75th percentile. Patient demographic factors, admission characteristics, health-related factors, and comorbidities were initially selected for the study based on clinical relevance and the literature, as well as availability in the data set.1 Pearson chi-square tests, Fisher’s exact test when appropriate, were used to examine the bivariable association between patient demographic and clinical factors and high length of stay for each procedure. Factors associated with high LOS at P < 0.25 in the bivariable tests were included in the selection of a multivariable logistic regression model for high LOS, adjusting for multiple factors. The final model for each procedure retained factors significantly associated with high LOS at P < 0.05. All analyses were conducted in the SAS Enterprise Guide 7.1 (SAS Institute, Inc., Cary, NC).

Results A total of 29,557 cases were identified across the nine procedure categories. Table 2 describes preoperative patient characteristics in the study population. Patients were most often 8 y or older (37.6% aged 8-12 y; 32.4% aged 13-18 y), male

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Table 3 e Percentiles for postoperative length of stay (days), NSQIP Pediatric: 2013-2015. Operation Overall

Cases (n)

Median

75th

80th

85th

90th

95th

97.5th

99th

29,557

1

3

4

5

6

8

11

16

13

Minimally invasive Laparoscopic appendectomy

19,260

1

2

3

4

5

7

9

Laparoscopic cholecystectomy

2424

1

1

1

2

2

3

4

5

Laparoscopic gastrostomy

1804

2

2

3

3

4

5

7

11

Laparoscopic fundoplication

1017

3

4

4

5

6

9

14

30

948

4

5

5

5

6

7

8

9

21

Thoracoscopic repair, pectus excavatum Open Open appendectomy

2060

3

6

6

7

9

12

14

Enterostomy closure

974

4

6

7

8

10

15

23

34

Gastrostomy closure

565

1

1

1

2

2

3

8

23

Open bowel resection

505

6

10

12

14

20

28

41

56

(57%), non-Hispanic (77.4%), white (73.3%), and admitted from the emergency room (ER; 68%). The following were the most prevalent preoperative health-related factors and comorbidities: American Society of Anesthesiologists (ASA) class 2 for mild disease (46.4%), systemic sepsis w/n 48 h before operation (33.4%), diabetes (21.6%), gastrointestinal disease (16.8%), and obese body mass index (weight for height ratio 95th percentile, 16.2%). Detailed patient characteristics by procedure are described in Supplementary Table S3. Table 3 describes procedure frequencies and detailed percentiles for LOS associated with each procedure in the study population. Among MIS procedures, the number of cases ranged from 19,260 (65.2% of the study population) for LA to 1017 (3.4%) for LF. Among open procedures, the number of cases ranged from 2060 (7%) for appendectomy to 505 (1.7%) for bowel resection. Procedure-specific 75th percentiles for LOS ranged from 1 (LC) to 5 d (thoracoscopic pectus repair),

among MIS procedures, and from 1 (gastrostomy closure) to 10 d (bowel resection), among open procedures (Fig. 1). Results from the regression modeling to identify significant preoperative risk factors for high LOS are summarized in Tables 4 (MIS procedures) and 5 (open procedures). The leading significant factors were admission and operative case characteristics, followed by health-related factors and comorbidities, and then sociodemographic factors. The effects of these factors on LOS varied by procedure. Among admission and operative case characteristics, ASA class was a significant factor for high LOS for five procedures: bowel resection, LC, open procedure, LA, with odds ratios (ORs) for severe disease-moribund class ranging from 3.8 to 2.1, and thoracoscopic pectus repair, with OR ¼ 1.8 for mild disease. Wound class was a significant factor for four procedures, namely LA (OR ¼ 20.0 for dirty/infected), LC (OR ¼ 4.6 for dirty/infected), enterostomy closure (OR ¼ 3.3 for clean), and

*90th pctile: 20 th

90 Percentile th

75 Percentile Median th

25 Percentile Minimum

Fig. 1 e Postoperative length of stay (LOS) by procedure. NSQIP Pediatric (n [ 29,557), 2013-2015. Minimally invasive procedures (L [ laparoscopic): LC [ cholecystectomy, LG [ gastrostomy, LA [ appendectomy, LF [ fundoplication, and TPE [ thoracoscopic repair of pectus excavatum. Open procedures (O [ open): OGC [ gastrostomy closure, OA [ appendectomy, OEC [ enterostomy closure, and OBR [ bowel resection.

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Table 4 e Odds ratios (ORs) for preoperative factors associated with excess length of stay (>75th percentile)dminimally invasive procedures. Variable

LA (n ¼ 19,260)

LC (n ¼ 2424)

LG (n ¼ 1804)

LF (n ¼ 1017)

TPE (n ¼ 948)

OR (95% CI)

OR (95% CI)

OR (95% CI)

OR (95% CI)

OR (95% CI)

Age group >6 to <12 mo

2.51 (0.47-13.30)

0.58 (0.36-0.92)

1-2 y

6.94 (5.09-9.46)

0.65 (0.42-1.02)

3-5 y

2.82 (2.43-3.28)

0.54 (0.33-0.89)

6-7 y

1.92 (1.67-2.21)

0.74 (0.42-1.30)

8-12 y

1.37 (1.24-1.52)

1.02 (0.64-1.64)

13-18 y

Reference

Reference 1.98 (1.31-3.01)

Female Hispanic ethnicity

1.28 (1.16-1.42)

1.58 (1.14-2.20)

Race White

Reference

Reference

Black

1.50 (1.30-1.74)

1.66 (1.23-2.24)

1.76 (1.26-2.46)

1.44 (0.88-2.35)

Asian

1.32 (1.02-1.69)

0.69 (0.19-2.51)

1.27 (0.75-2.17)

3.98 (1.56-10.16)

1.05 (0.70-1.57)

1.53 (0.90-2.61)

Other/unknown

1.02 (0.89-1.16)

1.16 (0.82-1.64)

Admitted from ER

1.22 (1.04-1.43)

3.39 (2.65-4.35)

Reference

Case type Elective

Reference

Urgent

1.53 (1.31-1.78)

Reference Reference

Emergent

1.20 (1.04-1.39)

6.81 (1.46-31.75)

ASA class Normal

Reference

Reference

Reference

Mild disease

1.10 (1.01-1.20)

1.41 (0.97-2.06)

1.83 (1.12-3.00)

Severe moribund

2.13 (1.75-2.58)

3.05 (1.97-4.72)

1.47 (0.60-3.65)

Clean

2.71 (2.07-3.56)

1.08 (0.72-1.62)

Clean/contaminated

1.22 (1.08-1.38)

Wound class

Contaminated

Reference

Dirty/infected

19.95 (18.11-21.98)

Reference 1.17 (0.84-1.62) 4.62 (1.67-12.79) 0.69 (0.52-0.91)

Premature birth (36 wk) BMI/weight for height percentile Normal/underweight (<85) Overweight (85-94) Obese (95) Unknown Systemic sepsis w/n 48 h before operation

1.85 (1.69-2.02) 1.46 (1.13-1.87)

Diabetes mellitus

2.07 (1.18-3.63)

Gastric/intestinal disease Pulmonary disease

0.79 (0.65-0.96)

Developmental delay

1.40 (1.03-1.91)

1.72 (1.07-2.78) 3.03 (1.35-6.79)

Neurologic disease Hematologic disease

2.64 (1.89-3.68)

1.71 (1.12-2.61)

Immune disease/ immunosuppressant use Renal insufficiency

5.94 (1.47-23.99)

Empty cells represent factors excluded from the final multivariable model because of lack of statistical significance (P  0.05). Bold values are statistically significnat with P < 0.05. ASA ¼ American Society of Anesthesiologists; BMI ¼ body mass index; ER ¼ emergency room; LA ¼ laparoscopic appendectomy; LC ¼ laparoscopic cholecystectomy; LF ¼ laparoscopic fundoplication; LG ¼ laparoscopic gastrostomy; TPE ¼ thoracoscopic repair of pectus excavatum.

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Table 5 e Odds ratios (ORs) for preoperative factors associated with excess length of stay (>75th percentile)dopen procedures. Variable

OA (n ¼ 2060)

OEC (n ¼ 974)

OGC (n ¼ 565)

OBR (n ¼ 505)

OR (95% CI)

OR (95% CI)

OR (95% CI)

OR (95% CI)

Age group >6 to <12 mo

0.80 (0.46-1.40)

0.98 (0.35-2.76)

1-2 y

1.36 (0.79-2.34)

0.36 (0.17-0.76)

3-5 y

1.98 (1.08-3.62)

0.49 (0.24-1.02)

6-7 y

1.50 (0.69-3.26)

0.27 (0.09-0.81)

8-12 y

1.63 (0.91-2.91)

0.71 (0.33-1.52)

13-18 y

Reference

Reference

Female Hispanic ethnicity Race White

Reference

Black

1.48 (0.98-2.24)

Asian

0.91 (0.41-2.00)

Other/unknown

1.62 (1.04-2.55) 5.15 (1.96-13.56)

Admitted from ER Case type Elective Urgent Emergent ASA class Normal

Reference

Reference

Mild disease

1.25 (0.97-1.62)

2.17 (0.87-5.43)

Severe moribund

2.92 (1.97-4.33)

3.79 (1.52-9.44)

Wound class 3.30 (1.23-8.91)

Clean

0.99 (0.40-2.46)

Clean/contaminated

0.09 (0.05-0.18)

Contaminated

0.11 (0.07-0.17)

1.03 (0.66-1.62)

Dirty/infected

Reference

1.07 (0.43-2.64)

Reference

1.94 (1.09-3.44)

Premature birth (36 wk) BMI/weight for height percentile Normal/under (<85)

Reference

Overweight (85-94)

1.97 (1.09-3.58)

Obese (95)

1.00 (0.55-1.80)

Unknown

0.54 (0.19-1.54)

Systemic sepsis w/n 48 h before operation

1.40 (1.06-1.86)

Diabetes mellitus

0.58 (0.41-0.81)

1.97 (1.20-3.23)

Gastric/intestinal disease Pulmonary disease 1.64 (1.11-2.41)

Developmental delay Neurologic disease

3.18 (1.80-5.62)

3.01 (1.35-6.70)

Hematologic disease Immune disease/immunosuppressant use

4.38 (1.73-11.07)

Renal insufficiency Empty cells represent variables excluded from the final multivariable model due to lack of statistical significance (P  0.05). Bold values are statistically significant with P < 0.05. ASA ¼ American Society of Anesthesiologists; BMI ¼ body mass index; ER ¼ emergency room; OA ¼ open appendectomy; OBR ¼ open bowel resection; OEC ¼ open enterostomy closure; OGC ¼ gastrostomy closure.

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open appendectomy (OR ¼ 0.10 for clean/contaminated). In addition, admission from the ER increased the odds of high LOS for three procedures (gastrostomy closure, LC, and LA; ORs ranging from 5.1 to 1.2), and being classified as an emergent case increased the odds for thoracoscopic pectus repair and LA (ORs: 6.8 and 1.2, respectively). Significant health-related factors and comorbidities included developmental delay (associated with high LOS for bowel resection, enterostomy closure, and LA; ORs ranging from 3.2 to 1.4), systemic sepsis within 48 h of operation (high LOS for bowel resection, LA, and open appendectomy; ORs ranging from 2.0 to 1.4), neurologic disease (OR ¼ 3.0 for both thoracoscopic pectus repair and open appendectomy), hematologic disease (ORs of 2.6 for LC and 1.7 for LG), and diabetes (ORs of 1.5 for LG and 0.6 for open appendectomy). Renal insufficiency (OR ¼ 5.9 for LG), immune disease (OR ¼ 4.4 for enterostomy closure), gastric/intestinal disease (OR ¼ 2.1 for LF), overweight body mass index (85-94th percentile; OR ¼ 2.0 for enterostomy closure), and pulmonary disease (OR ¼ 0.8 for LA) were the remaining significant health-related factors, each associated with LOS for just one of the procedures. Among sociodemographic factors, race and age were significant factors for five and four procedures, respectively. Non-white race was associated with greater odds of high LOS for the following procedures: LG, LC, LA (ORs for blacks ranging from 1.8 to 1.5), LF (OR ¼ 4.0 for Asians), and enterostomy closure (OR ¼ 1.6 for other non-white or unknown race). Age was a significant factor for LA (OR ¼ 6.9 for age 1-2 y), enterostomy closure (OR ¼ 1.98 for 3-5 y), LG (OR ¼ 0.54 for 3-5 y), and gastrostomy closure (OR ¼ 0.30 for 6-7 y). Hispanic ethnicity increased the odds of high LOS for LG and LA (ORs: 1.6 and 1.3, respectively), and female

gender was a significant factor for thoracoscopic pectus repair (OR ¼ 2.0). Frequency distributions for LOS were highly variable between procedures. By contrast, examination of LOS within each procedure category often yielded a narrow distribution centered about a modal peak within the 1 to 5 d range (Fig. 2). Examining LA, LC, and gastrostomy closure, the modal LOS value is 1 d, and the 75th percentile bound is at or before 2 d for each of the distributions (Fig. 1).

Discussion Policymakers and stakeholders require objective and relevant benchmarking when advocating for performance goals in health care. LOS thresholds have been identified as independent metrics by national patient advocacy organizations for quality improvement thoracic surgery8 and triggers for peer performance review.9 Measures to reduce LOS are frequently employed to curb rising costs of health care,1-4,10-17 though such efforts may result in modest savings18 and result in cost shifting.19 Attempts to use risk models to account for variation in LOS in the adult inpatient population have revealed that only 12%-28% of such variation can be attributed to known factors,20 suggesting opportunities for improvement at the provider and health system level. The present study demonstrates significant variability in postoperative LOS after common procedures in a multicenter, prospectively collected data set examining postoperative outcomes in pediatric surgery. Logistic regression analysis evaluating possible preoperative risk factors for outlier LOS was unable to identify reliable predictors across the

Fig. 2 e Distribution of postoperative length of stay (LOS) by procedure. NSQIP Pediatric, 2013-2015. (Color version of figure is available online.)

papandria et al  length of stay after pediatric surgery

procedures examined; the most consistent risk factors were significant for only a third of the included operations. Examining the specific significant risk factors by procedure, several trends emerge. For appendectomy, multiple risk factors likely represent known covariates with perforated appendicitis, such as age, race/ethnicity, and wound class. Similarly, the significant findings of race, wound class, and ASA class may reflect discrete patient subpopulations (i.e., those with acute cholecystitis versus those with symptomatic cholelithiasis). Comorbidities predicting longer LOS after gastrostomy tube placement would seem likely to complicate postoperative recovery, but the influence of patient demographics is not easily explained. Risk factors for increased LOS after fundoplication were also difficult to fully account for. Emergent designation of pectus excavatum would be reserved for patients with overt cardiorespiratory compromise secondary to the chest wall deformity, which would seem likely to prolong LOS, and a gender-specific difference in LOS has not been previously reported after this procedure. The ORs reflecting elevated risk for outlier LOS after enterostomy and gastrostomy closure are challenging to interpret, with the exception of the admission source for gastrostomy closure, which may reflect operations performed urgently to address site complications. Finally, risk factors for prolonged LOS after bowel resection appear reflective of poor baseline health status and acute preoperative comorbidity. These data represent the first attempt to broadly characterize LOS associated with specific, uncomplicated procedures across hospitals. The narrow focus on commonly performed procedures reported here may prove useful to quality improvement efforts across the broad spectrum of hospitals providing surgical care to children. LOS distributions for LA, LC, and gastrostomy closure are of particular interest. The relative uniformity of LOS distributions after these three procedures may present an opportunity for performance benchmarking. Significant limitations of the present study include the nonrandom sampling methodology used by the ACS NSQIP Pediatric clinical reviewers and possible selection bias related to institutional participation. Trends in LOS presented here may reflect unique practices used by hospitals engaged in a standardized quality improvement program, relative to nonparticipating centers. The magnitude of this type of bias would presumably be variable and therefore more evident when examining procedures with high rates of LOS variability. Finally, the lack of geographic or facility-specific identifiers in the NSQIP PUF precludes analyses of regional variability or comparisons between hospitals. Such LOS variability has been previously demonstrated as a quality improvement challenge when managing diverse medical problems, including asthma,21 lung resection,22 congenital cardiac surgery,23 and community-acquired pneumonia.24 Although centers participating in NSQIP receive periodic risk-adjusted reports of their performance relative to one another, not every hospital commands sufficient resources to deploy and maintain such a comprehensive quality improvement program. Smaller pediatric facilities, particularly low-volume surgical units housed within adult centers, may benefit from simple and objective benchmarks for use in quality improvement. Such measures should help direct

193

review of recent performance to better identify opportunities and areas of focus to ensure better outcomes for all children requiring surgery, irrespective of the venue where care is provided. Parallel examinations of LOS after common surgical procedures in non-NSQIP Pediatric practice settings or regional collaboratives would be useful to validate the findings presented in the present study. Finally, LOS should be periodically reassessed using the NSQIP Pediatric PUF, as the data will, over time, reflect significant improvements in pediatric surgical care at participating centers. Concern regarding unintended consequences of aggressive interventions to decrease LOS is reflected in various reports in the adult13,25,26 and pediatric12,14,27 literature. Therefore, any attempt to promulgate LOS benchmarking must be paired with assessments of balancing measures, such as unplanned readmission.

Acknowledgment This research was supported by the Department of Surgery and the Research Institute at Nationwide Children’s Hospital. Authors’ contributions: Drs D.P. and Y.V.S. contributed to the conception and design, the analysis and interpretation of data, as well as drafting and critical revision of the manuscript for important intellectual content. Dr Y.V.S. also participated in the acquisition of data. Dr K.J.D. contributed to the acquisition and analysis of data as well as critical revision of the manuscript for important intellectual content. Drs K.A.D. and P.C.M. participated in the conception and design as well as critical revision of the manuscript for important intellectual content. Dr P.C.M. also participated in acquisition, analysis, and interpretation of data. All authors have given final approval of the version to be published and agree to be accountable for its content.

Disclosure statement The authors have no significant personal or financial relationships to disclose that might influence the materials or conclusions presented here.

Supplementary data Supplementary data related to this article can be found at https://doi.org/10.1016/j.jss.2018.05.054.

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