Craig Gale

Enhanced recovery after colon surgery in a community hospital system.

BACKGROUND: Enhanced recovery after colon surgery has not been widely adopted in the United States and Europe, despite evidence that postoperative complications and hospital length of stay are decreased. OBJECTIVE: We sought to evaluate the introduction of a comprehensive care process for enhanced recovery after colon surgery in 8 community hospitals. DESIGN: A system-wide, surgeon-directed, multidisciplinary committee developed a comprehensive enhanced-care quality-improvement program. Surgeons and operations leaders in each hospital developed the internal structure to implement the process. PATIENTS: Surgeons had the option of entering or not entering patients in the enhanced-care pathway. Other than trauma patients, there were no exclusion criteria. MAIN OUTCOME MEASURES: To limit selection bias, the study population included all patients undergoing colon resections (those entered and not entered in the care process). Length of stay, postoperative days, hospital costs, 30-day readmission rate, and return to surgery for the study population were compared with a 2-year historical baseline. RESULTS: Forty-two percent of the study population was entered in the enhanced-care process. The average length of stay and the number of postoperative days in the study population decreased by 1.5 (P < .0001) and 1.3 (P < .0001) days. The rate of readmissions and returns to surgery remained stable (P > .05), and the average hospital cost decreased by

Hospital and Surgeon Adherence to Pediatric Tonsillectomy Guidelines Regarding Perioperative Dexamethasone and Antibiotic Administration.

1763 (P = .02). Generalized linear regression analysis demonstrated that the enhanced-care process was a more significant variable than was the surgical approach (laparoscopic vs open surgery) in decreasing length of stay. LIMITATIONS: The degree of compliance with care process elements and the relative contribution of each element of the care process are unknown. CONCLUSIONS: A comprehensive enhanced-care colon surgery care process was successfully introduced in a community hospital system, as indicated by the clinical outcome measures.

Surgeon and hospital cost variability for septoplasty and inferior turbinate reduction

Objectives To (1) determine adherence to American Academy of Otolaryngology—Head and Neck Surgery Foundation guidelines for pediatric tonsillectomy recommending routine administration of perioperative dexamethasone and against routine antibiotic administration among surgeons and hospitals in a multihospital network and (2) evaluate the impact of adherence on the risk of complications. Study Design Case series with chart review. Setting Multihospital network. Subjects and Methods A case series of 15,950 children aged 1 to 18 years undergoing same-day surgery adenotonsillectomy (T&A) within a multihospital network from 2008 to 2014 was reviewed to determine whether dexamethasone and/or antibiotics were given in the hospital. The frequency of dexamethasone and antibiotic administration was compared among surgeons and hospitals in the years before and after the guidelines were published. The frequency of complications was compared in adhering vs nonadhering surgeons. Results The study cohort included 15,950 children undergoing T&A at 19 hospitals by 74 surgeons. Of the patients before guideline publication, 98.4% (n = 7432) received dexamethasone compared with 98.9% of subjects after guideline publication (n = 8518). In total, 16.1% received antibiotics before the guidelines compared with 13.8% after. Prior to the guidelines, 27 of 74 surgeons (36%) routinely gave antibiotics. After the guidelines were published, 19 surgeons (26%) continued to give antibiotics more than 50% of the time. There was no difference in complication visits between adhering and nonadhering surgeons. Conclusions Most hospitals and surgeons administered perioperative dexamethasone routinely. While the overall frequency of antibiotic administration decreased after the guidelines were published, a significant percentage of surgeons continued to give antibiotics routinely, suggesting the need for improved dissemination and implementation of guidelines to promote adherence.

Hospital cost of pediatric patients with complicated acute sinusitis

Septoplasty and turbinate reduction (STR) is a common procedure for which cost reduction efforts may improve value. The purpose of this study was to identify sources of variation in medical facility and surgeon costs associated with STR, and whether these costs correlated with short‐term complications.

Primary Caregiver Perception of Pain Control following Pediatric Adenotonsillectomy: A Cross-Sectional Survey.

OBJECTIVE Review costs for pediatric patients with complicated acute sinusitis. METHODS A retrospective case series of patients in a pediatric hospital was created to determine hospital costs using a standardized activity-based accounting system for inpatient treatment between November 2010 and December 2014. Children less than 18 years of age who were admitted for complicated acute sinusitis were included in the study. Demographics, length of stay, type of complication and cost of care were determined for these patients. RESULTS The study included 64 patients with a mean age of 10 years. Orbital cellulitis (orbital/preseptal/postseptal cellulitis) accounted for 32.8% of patients, intracranial complications (epidural/subdural abscess, cavernous sinus thrombosis) for 29.7%, orbital abscesses (subperiosteal/intraorbital abscesses) for 25.0%, potts puffy tumor for 7.8%, and other (including facial abscess and dacryocystitis) for 4.7%. The average length of stay was 5.7 days. The mean cost per patient was

Variation in costs among surgeons and hospitals in Pediatric tympanostomy tube placement.

20,748. Inpatient floor costs (31%) and operating room costs (18%) were the two greatest expenditures. The major drivers in variation of cost between types of complications included pediatric intensive care unit stays and pharmacy costs. CONCLUSION Although complicated acute sinusitis in the pediatric population is rare, this study demonstrates a significant financial impact on the health care system. Identifying ways to reduce unnecessary costs for these visits would improve the value of care for these patients.

Comparison of pediatric adenoidectomy techniques: Impact of Adenoidectomy Methods

Objectives To (1) review pain medications prescribed following pediatric adenotonsillectomy (T&A), (2) identify pain medications reported to be helpful, and (3) compare parent-reported outcomes among various combinations of pain medications. Study Design Case series with planned data collection. Setting Multihospital network. Subjects and Methods The primary caregivers of children aged 1 to 18 years who underwent isolated T&A from June to December 2014 were contacted 14 to 21 days after surgery. Data collected included pain medications prescribed, medications most helpful in controlling pain, and duration that pain medication was required. Parents rated their children’s pain on postoperative days 2, 3, 7, and 14 and reported the time to resumption of normal diet/activity, as well as any hospital return visits. Results The study cohort included 672 subjects of 1444 potential participants (46% response rate). The mean age of the patients was 7.9 ± 3.6 years. Narcotics were prescribed in 71.9%, and 70.4% were told to use ibuprofen. Children who took ibuprofen alone were significantly younger (P < .001). Pain was significantly less on postoperative days 2 and 3 in the ibuprofen-only group as compared with the groups taking narcotics only (P < .001) and ibuprofen with narcotics (P = .002). Those taking ibuprofen alone returned to normal activity (P < .001) and diet (P = .026) sooner than those taking ibuprofen with narcotics. No difference was seen in pain control on subgroup analysis comparing oxycodone and hydrocodone. Conclusions For pediatric T&A, significant variation exists in the management of postoperative pain. Parents of children given ibuprofen reported less pain than those given narcotics with and without ibuprofen. Further studies are needed to identify the optimal pain regimen for children after T&A.

SYSTEMS AND METHODS FOR IMPROVED HEALTH CARE COHORT REPORTING

1) Identify the major expenses for outpatient pediatric tympanostomy tube placement in a multihospital network. 2) Compare differences for variations in costs among hospitals and surgeons.

Single-Stage Management of Common Bile Duct Stones with Laparoscopic Common Duct Exploration and Cholecystectomy is Safe and Cost Effective in a Large Multi-Hospital Health Care System

Evaluate the effects of electrocautery, microdebrider, and coblation techniques on outpatient pediatric adenoidectomy costs and complications.