Hospital Surgical Volume and Associated Postoperative Complications of Pediatric Urological Surgery in the United States (original) (raw)

Abstract

BACKGROUND-Hospital and provider surgical volume have been increasingly linked to surgical outcomes. However, this topic has rarely been addressed in children. Our objective was to investigate whether hospital surgical volume impacts complication rates in pediatric urology. METHODS-We retrospectively reviewed the Nationwide Inpatient Sample (1998-2011) for pediatric (≤ 18 years) admissions for urologic procedures. We used ICD-9-CM codes to identify elective urologic interventions and National Surgical Quality Improvement Program (NSQIP) inhospital post-operative complications. Annual hospital surgical volume was calculated and dichotomized as high-volume (>90 th percentile) or non-high-volume hospitals (<90 th percentile). RESULTS-In total, we identified 158,804 urologic admissions (114,634 high-volume hospital admissions and 44,171 non-high-volume hospital admissions). 75% of hospitals performed fewer than 5 major pediatric urology cases per year. High-volume hospitals treated significantly younger patients (mean 5.4 vs 9.6 years, p<0.001), and were more likely to be teaching hospitals (93% vs 71%, p<0.001). The overall rate of NSQIP-identified postoperative complications was higher at non-high-volume hospitals (11.6%) than at high-volume hospitals (9.3%, p=0.003). After adjusting for confounding effects, patients treated at non-high-volume hospitals remained more likely to suffer multiple NSQIP-tracked postoperative complications: acute renal failure (OR 1.4, p=0.04), UTI (OR 1.3, p=0.01), post-op respiratory complications (OR 1.5, p=0.01), systemic sepsis (OR 2.0, p=<0.001), post-op bleeding (OR 2.5, p<0.001), and in-hospital death (OR=2.2, p=0.007). CONCLUSIONS-Urologic procedures performed on children at non-high-volume hospitals were associated with an elevated risk of in-hospital, NSQIP-identified postoperative complications, including a small but significant increase in postoperative mortality mostly in nephrectomy and percutaneous nephrolithotomy.

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  29. <0.001 6-12 years 34,619 26,592 (23.2%) 8,027 (18.2%) 12-18 years 17,843 9,762 (8.5%) 8,081 (18.3%) 18-21 years 11,490 3,151 (2.7%) 8,339 (18.9%)
  30. Others 29,664 22,376 (19.5%) 7,287 (16.5%)
  31. Others 11,992 7,642 (6.7%) 4,351 (9.9%) Treatment year 1998-2004 82,136 59,107 (51.6%) 23,028 (52.1%) 0.89 2005-2011 76,671 55,526 (48.4%) 21,143 (47.9%) Surgery type Reimplant 74,585 59,406 (51.8%) 15,179 (34.4%) Ureteroureterostomy 1,835 1,515 (1.3%) 320 (0.7%) Pyeloplasty 36,672 24,286 (21.2%) 12,386 (28.0%)
  32. Bladder Neck Sling 1,158 673 (0.6%) 485 (1.1%)
  33. Characteristics Total n=158,804 High-Volume (n=114,634, %) Non-High-Volume (n=44,171, %) P-value Midwest 36,037 24,250 (21.2%) 11,788 (26.7%)
  34. West 39,236 27,737 (24.2%) 11,500 (26.0%) Teaching hospital Yes 138,516 107,242 (93.6%) 31,274 (70.8%)
  35. ZIP Code Median Income Q1 20,174 14,024 (12.2%) 6,151 (13.9%)