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Variations Between Hospitals in Antireflux Procedures in Children

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Variations Between Hospitals in Antireflux Procedures in Children ARTICLE Variations Between Hospitals in Antireflux Procedures in Children Adam B. Goldin, MD, MPH; Michelle Garrison, PhD; Dimitri Christakis, MD, MPH Objective: To examine the differences and trends in nonincidental appendectomies, 14 895 pyloromyoto- pediatric antireflux procedures (ARPs) across individual mies, and 23 527 gastrostomy tube placements were pediatric hospitals over time. identified. The average number of ARPs per appendec- tomy, pyloromyotomy, and gastrostomy tube place- Design: Retrospective cohort study. ment declined annually across free-standing pediatric institutions. When these annual changes are examined Setting: Administrative database containing inpatient within each hospital individually, however, it appears records with discharge dates between January 1, 2001, that such changes are not occurring equally, in that and March 31, 2006. some hospitals are performing significantly greater and some significantly fewer ARPs relative to these common Participants: Hospitalized pediatric patients younger procedures. than 18 years with primary procedure codes for ARP, ap- pendectomy, pyloromyotomy, and gastrostomy tube Conclusions: The number of ARPs being performed in placement. The comparisons with admissions for these 36 free-standing children’s hospitals is decreasing each common procedures were used to identify changes in the year relative to several operations commonly performed incidence of ARP per hospital per year. at these institutions. Despite this overall annual de- Main Outcome Measures: The ratio of ARPs to ap- crease, there is tremendous variation between indi- pendectomies, pyloromyotomies, gastrostomies, and all vidual hospitals in how frequently ARPs are being per- 3 procedures combined, in each hospital by year. formed relative to these procedures. Results: During our study period 13 691 ARPs, 41 441 Arch Pediatr Adolesc Med. 2009;163(7):658-663 ASTROESOPHAGEAL RE- performed. A recent study examining na- flux disease (GERD), the tional trends in the use of ARP, however, pathologic and sympto- concluded that the indications for ARPs matic reflux of gastric have “evolved during the laparoscopic era,” content into the esopha- in that fewer operations are performed on gus, affects about 7% of infants in the first neurologically impaired children or on G1,2 7 year of life. The indication for referral children after infancy. A recent study used for surgical therapy for GERD is most com- the Nationwide Inpatient Sample coupled monly a failure to respond to medical man- with census data to identify national popu- agement, though some are also referred lation-based trends with respect to ARP. based on their medical comorbidities for Citing a study that demonstrated varia- prophylactic procedures, given the per- tion between individual hospitals and na- Author Affiliations: ceived natural history and risks associ- tional trends, the authors also stated that Department of General and ated with these underlying problems.3 they were not able to address how local Thoracic Surgery, Seattle Antireflux procedures (ARPs) are com- variations in the use of ARP may affect in- Children’s Hospital mon in children and are being performed fants and children.8 (Dr Goldin); Child Health with increasing frequency.3,4 Many stud- While on the macrolevel it is ex- Institute, University of ies described excellent outcomes after ARP, tremely helpful to identify the national Washington (Dr Garrison); and with greater than 90% resolution of symp- trend in the rate of ARPs, it raises many the Center for Child Health, 5,6 Behavior, and Development, toms and improved quality of life. Given questions. Among them is whether this Seattle Children’s Hospital the prevalence of GERD and the reported trend is universal or if it is specific to a re- Research Institute, Seattle, success of ARP, it is not surprising that, gion, hospital, group practice, or even to Washington (Drs Garrison and historically, it has been described as one an individual surgeon. While a moderate Christakis). of the most common surgical procedures amount of variation in practice patterns be- (REPRINTED) ARCH PEDIATR ADOLESC MED/ VOL 163 (NO. 7), JULY 2009 WWW.ARCHPEDIATRICS.COM 658 ©2009 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 10/01/2021 tween local groups or individuals is expected, large varia- PATIENTS tions might suggest either similarly large variation in the indications for the operation or in the preoperative assess- Our study included pediatric patients younger than 18 years with ment and decision making. This is important, in that to iden- discharge dates between January 1, 2001, and March 31, 2006. tify valid measures of outcomes of an intervention like ARP The primary sample included all patients with procedure codes beyond universal measures such as death or length of stay, for ARP (ICD-9 procedure codes 44.66-44.67). Comparison samples were drawn for patients meeting the same age and date we must first identify the indications. For example, if chil- criteria, with procedure codes for appendectomy, pyloromy- dren have an ARP for aspiration pneumonia, it would be otomy, and gastrostomy; individual patients may be represented ideal to identify a cessation of events of aspiration pneu- in more than 1 category, although this was rare. Unique patient monia after the operation. A recent article demonstrated identifiers were used, however, to ensure that an individual pa- that when evaluating ARPs by more specific disease- tient only counted toward a category for the first admission, even related outcomes such as rate of hospitalizations for GERD- if subsequent admissions occurred with the same procedure code. related diagnoses like aspiration pneumonia, some chil- dren were hospitalized more frequently after compared with VARIABLES OF INTEREST before.9 No published articles to date describe clustered or re- Other variables examined included demographic characteris- gional prevalence of regurgitation or GERD and, simi- tics (age, sex, Medicaid status), hospital stay characteristics (year larly, no data suggest clustered or regional severity of dis- of discharge, length of stay, intensive care unit use, laparo- scopic procedures), and relevant comorbid conditions. ease. Given the lack of demonstrable clustering of the presence or severity of GERD across the United States, STATISTICAL ANALYSIS if the indications for ARP are standard, one would ex- pect that ARPs would be performed equally often in pe- The distribution of collected variables was described across each diatric hospitals nationwide. Our hypothesis, therefore, of the operative categories. The ratio of antireflux operations is that a critical evaluation of the incidence of ARPs should to each of appendectomy, pyloromyotomy, and gastrostomy pro- not exhibit regional or clustered patterns. The aim of this cedures were then calculated by year at the hospital level. As study is to examine differences in the annual rate of pe- only one-fourth of the data were available for 2006, ratios were diatric antireflux operations across individual pediatric only calculated for the years 2001 through 2005. The distri- hospitals over time. bution of ratios across hospitals was then examined, calculat- ing the median, range, and interquartile range. To test for changes in the procedures over time within the METHODS hospitals, a series of linear regression analyses were per- formed with hospital as a fixed effect. The unit of analysis for We performed a retrospective examination of pediatric hospi- these regressions was a given year of data within an individual tal discharge data relevant to antireflux operations. Issues ex- hospital, and the coefficient for the discharge year was exam- plored included differences across hospitals and trends over time. ined. Again, only data for the years 2001 through 2005 were Hospital-level denominator data were not feasible given the included for these analyses, as the outcome of interest was the absence of clearly defined catchment areas for admissions to total number of antireflux operations for the year. Four regres- free-standing children’s hospitals. As a result, we used com- sion models were tested, controlling for (1) the number of parisons with admissions for other relatively common gastro- appendectomy procedures during the year for each hospital, intestinal surgical procedures as a proxy, assuming that the re- (2) the same for pyloromyotomy and (3) gastrostomy, and ferral patterns and incidence of these comparison operative (4) including the annual figures for all 3 procedures. These analy- procedures should remain relatively stable within institutions ses allowed us to estimate the annual change in the number of over time. For example, as the incidence of appendicitis in chil- antireflux procedures across hospitals. dren would be expected to stay relatively constant over the study In a secondary post hoc analysis, we used the KID data with period, a decrease in the ratio of antireflux operations to ap- population-based sample weights to estimate the total proportion pendectomy procedures within a hospital would suggest a drop ofpediatricadmissionsforeachprocedurethatwerecapturedwithin in the frequency of antireflux operations. the PHIS database, with the aim of adding context to the overall findings. Unique patient identifiers were not available within the public-use KID data files, however, so repeat admissions of the DATA SOURCE same child within a category could not be excluded. This study was approved
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