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Tejwani R et al, 2016: Increased pediatric sub-specialization is associated with decreased surgical complication rates for inpatient pediatric urology procedures.

Tejwani R, Wang HS, Wolf S, Wiener JS, Routh JC.
Division of Urologic Surgery, Duke University Medical Center, Durham, NC, USA.
Division of Pediatric Anesthesia, Duke University Medical Center, Durham, NC, USA.
Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, NC, USA.

Abstract

INTRODUCTION: Increased case volumes and training are associated with better surgical outcomes. However, the impact of pediatric urology sub-specialization on perioperative complication rates is unknown.

OBJECTIVES: To determine the presence and magnitude of difference in rates of common postoperative complications for elective pediatric urology procedures between specialization levels of urologic surgeons. The Nationwide Inpatient Sample (NIS), a nationally representative administrative database, was used.

STUDY DESIGN: The NIS (1998-2009) was retrospectively reviewed for pediatric (≤18 years) admissions, using ICD-9-CM codes to identify urologic surgeries and National Surgical Quality Improvement Program (NSQIP) inpatient postoperative complications. Degree of pediatric sub-specialization was calculated using a Pediatric Proportion Index (PPI), defined as the ratio of children to total patients operated on by each provider. The providers were grouped into PPI quartiles: Q1, 0-25% specialization; Q2, 25-50%; Q3, 50-75%; Q4, 75-100%. Weighted multivariate analysis was performed to test for associations between PPI and surgical complications.

RESULTS: A total of 71,479 weighted inpatient admissions were identified. Patient age decreased with increasing specialization: Q1, 7.9 vs Q2, 4.8 vs Q3, 4.8 vs Q4, 4.6 years, P < 0.01). Specialization was not associated with race (P > 0.20), gender (P > 0.50), or comorbidity scores (P = 0.10). Mortality (1.5% vs 0.2% vs 0.3% vs 0.4%, P < 0.01) and complication rates (15.5% vs 11.7% vs 9.6% vs 10.9%, P < 0.0001) both decreased with increasing specialization. Patients treated by more highly specialized surgeons incurred slightly higher costs (Q2, +4%; Q3, +1%; Q4 + 2%) but experienced shorter length of hospital stay (Q2, -5%; Q3, -10%; Q4, -3%) compared with the least specialized providers. A greater proportion of patients treated by Q1 and Q3 specialized urologists had CCS ≥2 than those seen by Q2 or Q4 urologists (12.5% and 12.2%, respectively vs 8.4% and 10.9%, respectively, P = 0.04). Adjusting for confounding effects, increased pediatric specialization was associated with decreased postoperative complications: Q2 OR 0.78, CI 0.58-1.05; Q3 OR 0.60, CI 0.44-0.84; Q4 OR 0.70, CI 0.58-0.84; P < 0.01.

DISCUSSION: Providers with proportionally higher volumes of pediatric patients achieved better postoperative outcomes than their less sub-specialized counterparts. This may have arisen from increased exposure to pediatric anatomy and physiology, and greater familiarity with pediatric techniques.

LIMITATION: The NIS admission-based retrospective design did not enable assessment of long-term outcomes, repeated admissions, or to track a particular patient across time. The study was similarly limited in evaluating the effect of pre-surgical referral patterns on patient distributions.

CONCLUSIONS: Increased pediatric sub-specialization among urologists was associated with a decreased risk of mortality and surgical complications in children undergoing inpatient urologic procedures.

J Pediatr Urol. 2016 Jun 16. pii: S1477-5131(16)30126-7. doi: 10.1016/j.jpurol.2016.05.034. [Epub ahead of print]

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Comments 1

Hans-Göran Tiselius on Friday, 09 September 2016 12:15

This article deals with a comparison between SWL and URS carried out in a paediatric population. The end-points were repeated treatments and the need of ER or GU follow-up.

Unfortunately there was no information on the initial stone problem or on the outcome in terms of stone free rate or occurrence of residuals.

The most important finding was that children treated with URS had a higher rate of readmission and emergency room visits during the first 30 days than those treated with SWL. On the other hand SWL-treated children required slightly more additional consultations (19%), compared with URS (14%), a significant but small difference.

That the authors, from the presented results, suggest a discussion to change treatment recommendations in direction towards URS instead of a non-invasive treatment modality cannot easily be understood, particularly since the re-treatment rate after SWL generally was low and only explained by the predicted higher rate of re-treatments following SWL. This conclusion seems to be an adaptation to the present trend towards endoscopic procedures.

This article deals with a comparison between SWL and URS carried out in a paediatric population. The end-points were repeated treatments and the need of ER or GU follow-up. Unfortunately there was no information on the initial stone problem or on the outcome in terms of stone free rate or occurrence of residuals. The most important finding was that children treated with URS had a higher rate of readmission and emergency room visits during the first 30 days than those treated with SWL. On the other hand SWL-treated children required slightly more additional consultations (19%), compared with URS (14%), a significant but small difference. That the authors, from the presented results, suggest a discussion to change treatment recommendations in direction towards URS instead of a non-invasive treatment modality cannot easily be understood, particularly since the re-treatment rate after SWL generally was low and only explained by the predicted higher rate of re-treatments following SWL. This conclusion seems to be an adaptation to the present trend towards endoscopic procedures.
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